Questions Unit 1

Which of the following choices can the nurse teach a prenatal client is equivalent to one 2-oz meat serving? 1. 4 tbsp peanut butter. 2. 2 eggs. 3. 1 cup cooked lima beans. 4. 2 ounces mixed nuts.

2 2 eggs 1 meat serving.

A father experiencing couvade syndrome is likely to exhibit which of the following symptoms/behaviors? 1. Heartburn. 2. Promiscuity. 3. Hypertension. 4. Indifference.

1 Heartburn is a common symptom.

When assessing the psychological adjustment of an 8-week gravida, which of the following would the nurse expect to see signs of? 1. Ambivalence. 2. Depression. 3. Anxiety. 4. Ecstasy.

1 It is common for women to be am- bivalent about their pregnancy during the first trimester.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

1 The tracing is showing a normal fetal heart tracing. No intervention is needed.

A mother has just experienced quickening. Which of the following developmental changes would the nurse expect to occur at the same time in the woman's pregnancy? 1. Fetal heart begins to beat. 2. Lanugo covers the fetal body. 3. Kidneys secrete urine. 4. Fingernails begin to form.

2 Lanugo does cover the fetal body at approximately 20 weeks' gestation.

A client, G1P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and de- viated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary health care provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

2 This action is the first that the nurse should take.

The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order? 1. During the neonatal period, babies absorb fat-soluble vitamins poorly. 2. Breast milk and formula contain insufficient quantities of vitamin K. 3. The neonatal gut is sterile. 4. Vitamin K prevents hemolytic jaundice.

3 It takes about 1 week for the baby to be able to synthesize his or her own vitamin K. The gut, at birth, is sterile.

The childbirth educator is teaching a class of pregnant couples the breathing tech- nique that is most appropriate during the second stage of labor. Which of the fol- lowing techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing.

3 Open glottal pushing is used during stage 2 of labor.

Which of the following skin changes should the nurse highlight for a pregnant woman's health care practitioner? 1. Linea nigra. 2. Melasma. 3. Petechiae. 4. Spider nevi.

3 Petechiae are pinpoint red or purple spots on the skin. They are seen in hemorrhagic conditions.

A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Place child in isolette. 2. Administer oxygen. 3. Swaddle baby in blanket. 4. Apply pulse oximeter.

3 The baby's extremities are cyanotic as a result of the baby's immature circu- latory system. Swaddling helps to warm the baby's hands and feet.

The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3 The blood volume does drop precipi- tously during the early postpartum period.

A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby? 1. Carotid. 2. Radial. 3. Brachial. 4. Pedal.

3 The recommended site for assessing the pulse of a neonate undergoing CPR is the brachial pulse.

A woman is 36-weeks' gestation. Which of the following tests will be done during her prenatal visit? 1. Glucose challenge test. 2. Amniotic fluid volume assessment. 3. Vaginal and rectal cultures. 4. Karyotype analysis.

3 Vaginal and rectal cultures are done at approximately 36 weeks' gestation.

A vegan is being counseled regarding vitamin intake. It is essential that this woman supplement which of the following B vitamins? 1. B1 (thiamine). 2. B2 (niacin). 3. B6 (pyridoxine). 4. B12 (cobalamin).

4 Vitamin B12 (cobalamin) should be supplemented.

It is discovered that a pregnant woman practices pica. Which of the following com- plications is most often associated with this behavior? 1. Hypothyroidism. 2. Iron deficiency anemia. 3. Hypercalcemia. 4. Overexposure to zinc.

2 Iron deficiency anemia is often seen in clients who engage in pica.

A mother, who gave birth 5 minutes ago, states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first? 1. Assist the woman to breastfeed. 2. Assess the baby's blood pressures. 3. Administer the ophthalmic prophylaxis. 4. Take the baby's rectal temperature.

1 Breastfeeding should be instituted as soon as possible to promote milk pro- duction, stability of the baby's glucose levels, and meconium excretion, as well as to stabilize the baby's temper- ature through skin-to-skin contact.

A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.

1 Clients should be strongly encour- aged exclusively to breastfeed their babies to prevent engorgement.

During a prenatal visit, a gravid client is complaining of ptyalism. Which of the following nursing interventions is appropriate? 1. Encourage the woman to brush her teeth carefully. 2. Advise the woman to have her blood pressure checked regularly. 3. Encourage the woman to wear supportive hosiery. 4. Advise the woman to avoid eating rare meat.

1 Clients who experience ptyalism have an excess of saliva. They should be advised to be vigilant in the care for their teeth and gums. Ptyalism is of- ten accompanied by gingivitis and nausea and vomiting.

On examination, it is noted that a full-term primipara in active labor is right occipi- toanterior (ROA), 7 cm dilated, and 3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

1 Descent is progressing well. The pre- senting part is 3 centimeters below the ischial spines.

The nurse is initiating discharge teaching with a couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple: 1. on admission to the labor room. 2. in the client room after the delivery. 3. when the client put the baby to the breast for the first time. 4. the day before the client and baby are to leave the hospital.

1 Discharge teaching should be initiated at the time of admission. This nurse is correct in initiating the process in the labor room.

Which of the following nursing interventions would be appropriate for the nurse to perform in order to achieve the client care goal: The client will not develop post- partum thrombophlebitis? 1. Encourage early ambulation. 2. Promote oral fluid intake. 3. Massage the legs of the client twice daily. 4. Provide the client with high fiber foods.

1 Early ambulation does help to prevent thrombophlebitis.

Which of the following is the priority nursing action during the immediate post- partum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

1 Fundal assessment is the priority nursing action.

A mother is experiencing nausea and vomiting every afternoon. The ingestion of which of the following spices has been shown to be a safe complementary therapy for this complaint? 1. Ginger. 2. Sage. 3. Cloves. 4. Nutmeg.

1 Ginger has been shown to be a safe antiemetic agent for pregnant women.

Because nausea and vomiting are such common complaints of pregnant women, the nurse provides anticipatory guidance to a 6-week gestation client by telling her to do which of the following? 1. Avoid eating greasy foods. 2. Drink orange juice before rising. 3. Drink 2 glasses of water with each meal. 4. Eat 3 large meals plus a bedtime snack.

1 Greasy foods should be avoided.

Thenursenoteseachofthefollowingfindingsina12-weekgestationclient.Whichof the findings would enable the nurse to tell the client that she is positively pregnant? 1. Fetal heart rate via Doppler. 2. Positive pregnancy test. 3. Positive Chadwick's sign. 4. Montgomery gland enlargements.

1 Hearing a fetal heart rate is a positive sign of pregnancy.

A client enters the prenatal clinic. She states that she believes she is pregnant. Which of the following hormone elevations will indicate a high probability that the client is pregnant? 1. Chorionic gonadotropin. 2. Oxytocin. 3. Prolactin. 4. Luteinizing hormone.

1 High levels of the hormone chorionic gonadotropin in the bloodstream and urine of the woman is a probable sign of pregnancy.

Which of the following choices includes the correct order of the cardinal moves of labor? 1. Internal rotation, extension, external rotation. 2. External rotation, descent, extension. 3. Extension, flexion, internal rotation. 4. External rotation, internal rotation, expulsion.

1 Internal rotation, extension, external rotation is the correct sequence of the cardinal moves of labor.

The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatalogist? 1. Intracostal retractions. 2. Caput succedaneum. 3. Epstein's pearls. 4. Harlequin sign.

1 Intracostal retractions are a sign of respiratory distress.

The nurse is concerned that a bottlefed baby may become obese because of which activity by the mother? 1. She encourages the baby to finish the bottle at each feed. 2. She feeds the baby every 3 to 4 hours. 3. She feeds the baby a soy-based formula. 4. She burps the baby every 1⁄2 to 1 ounce.

1 It has been shown that bottlefed ba- bies are at higher risk for obesity than breastfed babies. One of the reasons is the insistence by some mothers that the baby finish the formula in a bottle even if the baby initially rejects it. The increased calorie intake leads to increased weight gain.

The nursing diagnosis—risk for suffocation—is included in a standard care plan in the neonatal nursery. Which of the following outcome goals should be included in relation to this diagnosis? 1. Baby is placed supine for sleep. 2. Baby is breastfed in the side-lying position. 3. Baby is swaddled when in the open crib. 4. Baby is strapped when seated in a car seat.

1 It has been shown that many neonatal SIDS deaths result from a form of suffocation. Babies breathe in their own exhaled carbon dioxide when they are placed prone for sleep. Ba- bies should be placed supine.

The nurse is caring for a postpartum client who experienced a second-degree per- ineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

1 It is appropriate to apply an ice pack to the area.

A nurse is advising a mother of a neonate being discharged from the hospital re- garding car seat safety. Which of the following should be included in the teaching plan? 1. Put the car seat facing forward only after the baby reaches twenty pounds. 2. The baby's car seat should be placed facing the rear in the front seat of the car. 3. A fist should fit between the straps of the seat and the baby's body. 4. Seat belt adjusters should always be used to support infant car seats.

1 It is unsafe for infants to be facing forward until they have reached 20 pounds, even if they are over 1 year of age.

Which of the following complementary therapies can a nurse suggest to a multi- parous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink iced tea with lemon or lime.

1 Lying prone on a pillow helps to re- lieve some women's afterbirth pains.

Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is high risk for physiological jaundice? 1. Cephalhematoma. 2. Caput succedaneum. 3. Harlequin coloring. 4. Mongolian spotting.

1 Red blood cells in the cephalhe- matoma will have to be broken down and excreted. The byproduct of the destruction—bilirubin—increases the baby's risk for physiological jaundice.

A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see? 1. Baby is showing signs of hunger and frustration. 2. Baby is starting to whimper and cry. 3. Baby is wide awake and attending to a picture. 4. Baby is asleep and breathing rhythmically.

1 Showing signs of hunger and frustra- tion describes the active alert or active awake state.

A breastfeeding mother refuses to place her unclothed baby face down on her chest because, "Babies are always supposed to be put on their backs. Babies who are on their stomachs die from SIDS." The nurse's action should be based on which of the following? 1. Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature. 2. The risk of SIDS increases whenever unsupervised babies are placed in the supine position. 3. SIDS rarely occurs before the completion of the neonatal period. 4. Back-to-sleep guidelines have been modified for breastfeeding babies.

1 Skin-to-skin contact (kangaroo care) has been shown to have many benefits for neonates, including promoting breast latch and stabilizing neonatal temperatures.

A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a ce- sarean delivery, fetal position LMA, under epidural anesthesia. Which of the fol- lowing physiological findings would the nurse expect to see? 1. Soft pulmonary rales. 2. Absent bowel sounds. 3. Depressed Moro reflex. 4. Positive Ortolani sign.

1 Soft rales are expected because babies born via cesarean section do not have the advantage of having the amniotic fluid squeezed from the pulmonary system as occurs during a vaginal birth.

A gravida's fundal height is noted to be at the xiphoid process. The nurse is aware that which of the following fetal changes is likely to be occurring at the same time in the pregnancy? 1. Surfactant is formed in the fetal lungs. 2. Eyes begin to open and close. 3. Respiratory movements begin. 4. The spinal column is completely formed.

1 Surfactant is usually formed in the fetal lungs by the 36th week.

A G1P0, 8 cm dilated, is to receive pain medication. The health care practitioner has decided to order an opiate analgesic with an analgesic-potentiating medication. Which of the following medications would the nurse expect to be ordered as the analgesic-potentiating medication? 1. Seconal (secobarbital). 2. Phenergan (promethazine). 3. Benadryl (diphenhydramine). 4. Tylenol (acetaminophen).

1 Talking and laughing are characteris- tic behaviors of the latent phase.

Which of the following findings in an 8-week gestation client, G2 P1001, should the nurse highlight for the nurse midwife? 1. Body mass index of 17. 2. Blood pressure of 100/60. 3. Hematocrit of 36%. 4. Hemoglobin of 13.2.

1 The BMI of 17 is of concern. This client is entering her pregnancy un- derweight.

Immediately after delivery, a woman is shaking uncontrollably. Which of the fol- lowing nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in Trendelenburg position. 3. Notify the primary health care provider. 4. Increase the intravenous infusion.

1 The appropriate action is to provide the client with warm blankets.

A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? 1. Do nothing because this is a normal weight loss. 2. Notify the neonatalogist of the significant weight loss. 3. Advise the mother to bottlefeed the baby at the next feed. 4. Assess the baby for hypoglycemia with a glucose monitor.

1 The baby has lost less than 4% of its birth weight. The normal weight loss for babies is 5% to 10%.

Which of the following vital sign changes should the nurse highlight for a pregnant woman's obstetrician? 1. Prepregnancy blood pressure (BP) 100/60 and third trimester BP 140/90. 2. Prepregnancy respiratory rate (RR) 16 rpm and third trimester RR 22 rpm. 3. Prepregnancy heart rate (HR) 76 bpm and third trimester HR 88 bpm. 4. Prepregnancy temperature (T) 98.6oF and third trimester T 99.2oF.

1 The blood pressure should not ele- vate during pregnancy. This change should be reported to the health care practitioner.

The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station 2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix.

1 The cervix is thin.

The nurse in the obstetric clinic received a telephone call from a bottlefeeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary health care provider to order a milk suppressant.

1 The client should apply ice packs to her axillae and breasts.

A gravida, G1 P0000, is having her first prenatal physical examination. Which of the following assessments should the nurse inform the client that she will have that day? 1. Pap smear. 2. Mammogram. 3. Glucose challenge test. 4. Biophysical profile.

1 The client will have a Pap smear done.

The nurse has taken a health history on four primigravid clients at their first prena- tal visits. It is high priority that which of the clients receives nutrition counseling? 1. The woman diagnosed with phenylketonuria. 2. The woman who has Graves' disease. 3. The woman with Cushing's syndrome. 4. The woman diagnosed with myasthenia gravis.

1 The client with phenylketonuria (PKU) must receive counseling from a registered dietitian.

A woman is in active labor and is being monitored electronically. She has just re- ceived Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.

1 The fetal heart rate normally acceler- ates during fetal movement.

A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the fol- lowing actions should the nurse perform first? 1. Compare mother's and baby's identification bracelets. 2. Help the mother into a comfortable position. 3. Teach the mother about a proper breast latch. 4. Tickle the baby's lips with the mother's nipple.

1 The first action the nurse should ever perform is to make sure that the cor- rect baby is being given to the correct mother.

A nurse reads that the neonatal mortality rate in the United States for a given year was 5. The nurse interprets that information as: 1. 5 babies less than 28 days old per 1000 live births died. 2. 5 babies less than 1 year old per 1000 live births died. 3. 5 babies less than 28 days old per 100,000 births died. 4. 5 babies less than 1 year old per 100,000 births died.

1 The neonatal period is defined as the first 28 days of life. The neonatal mortality rate is defined as neonatal deaths per 1000 live births. There- fore, 5 babies less than 28 days old per 1000 live births died.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia 4. Decreased respiratory rate.

1 The nurse would expect the woman to be 2 cm dilated.

The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA) 2. Left sacral posterior (LSP) 3. Right mentum anterior (RMA) 4. Right sacral posterior (RSP)

1 The nurse's findings upon performing Leopold's maneuvers indicate that the fetus is in the left occiput anterior po- sition (LOA)—that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal re- gion, and the head is felt above her symphysis.

A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother? 1. The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head. 2. The fetal head is flexed so that it is of average diameter. 3. The mother's cervix is of average dilation for the start of labor. 4. The distance between the mother's physiological retraction ring and the fetal head is of average dimensions.

1 The obstetric conjugate is the short- est anterior to posterior diameter of the pelvis. When it is of average size, it will accommodate an average-sized fetal head.

The nurse is teaching the parents of a female baby how to change the baby's dia- pers. Which of the following should be included in the teaching? 1. Always wipe the perineum from front to back. 2. Remove any vernix caseosa from the labial folds. 3. Put powder on the buttocks every time the baby stools. 4. Weigh every diaper in order to assess for hydration.

1 The perineum of female babies should always be cleansed from front to back to prevent bacteria from the rectum from causing infection.

The nurse is assisting a couple to develop decisions for their birth plan. Which of the following decisions should be considered nonnegotiable by the parents? 1. Whether or not the father will be present during labor. 2. Whether or not the woman will have an episiotomy. 3. Whether or not the woman will be able to have an epidural. 4. Whether or not the father will be able to take pictures of the delivery.

1 The presence of the father at delivery should be nonnegotiable.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assess- ments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal po

1 The relationship between the deceler- ations and the contractions will deter- mine the type of deceleration pattern.

The nurse asks a woman about how the woman's husband is dealing with the preg- nancy. The nurse concludes that counseling is needed when the woman makes which of the following statements? 1. "My husband is ready for the pregnancy to end so that we can have sex again." 2. "My husband has gained quite a bit of weight during this pregnancy." 3. "My husband seems more worried about our finances now than before the pregnancy." 4. "My husband plays his favorite music for my belly so the baby will learn to like it."

1 The woman implies that she and her husband are not having sex. There is no need to refrain from sexual inter- course during a normal pregnancy— so the woman and her husband need further counseling.

Which of the following actions would the nurse expect to perform immediately be- fore a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1000 cc of Ringer's lactate. 3. Place woman in Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have woman empty her bladder.

1 The woman should be helped into the fetal position.

A gravid woman who recently emigrated from mainland China is being seen at her first prenatal visit. She was never vaccinated in her home country. An injection to prevent which of the following communicable diseases should be administered to the woman during her pregnancy? 1. Influenza. 2. Mumps. 3. Rubella. 4. Varicella.

1 The woman should receive the in- fluenza injection. The nasal spray, however, should not be administered to a pregnant woman.

A gravid woman and her husband inform the nurse that they have just moved into a three-story home that was built in the 1930s. Which of the following is critical for the nurse to advise the woman in order to protect the unborn child? 1. Stay out of any rooms that are being renovated. 2. Drink water only from the hot water tap. 3. Refrain from entering the basement. 4. Climb the stairs only once per day.

1 The woman should stay out of rooms that are being renovated.

A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate? 1. "No, there are no foods that are strictly contraindicated while breastfeeding." 2. "Yes, the same foods that were dangerous to eat during pregnancy should be avoided." 3. "Yes, foods like onions, cauliflower, broccoli, and cabbage make babies very colicky." 4. "Yes, spices from hot and spicy foods get into the milk and can bother your baby."

1 There are no foods that are absolutely contraindicated during lactation. Some babies may react to certain foods, but this must be determined on a case-by-case basis.

A 2-day-old baby's blood values are: blood type—O (negative). direct Coombs—(negative). hematocrit—50%. bilirubin—1.5 mg/dL. The mother's blood type is A . What should the nurse do? 1. Do nothing because the results are within normal limits. 2. Assess the baby for opisthotonic posturing. 3. Administer RhoGAM to the mother per doctor's order. 4. Call the doctor for an order to place the baby under bili-lights.

1 These findings are all within normal limits.

An Asian client's temperature 10 hours after delivery is 100.2oF. She refuses to drink her iced water. Which of the following actions is most appropriate? 1. Replace the iced water with hot water. 2. Notify the client's health care provider. 3. Assess the client's breasts for engorgement. 4. Remind the client that drinking is very important.

1 This action is appropriate. Asians, many of whom believe in the hot-cold theory of disease, will often not drink cold fluids or eat cold foods during the postpartum.

A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? 1. Respiratory rate 8 rpm. 2. Complaint of thirst. 3. Urinary output of 250 cc/hr. 4. Numbness of feet and ankles.

1 This action is appropriate. This client's respiratory rate is below normal.

The obstetrician has ordered that a post-op cesarean section client's patient- controlled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate? 1. Discard the remaining medication in the presence of another nurse. 2. Recommend waiting until her pain level is zero to discontinue the medicine. 3. Discontinue the medication only after the analgesia is completely absorbed. 4. Return the unused portion of medication to the narcotics cabinet.

1 This answer is correct. Because the medication in a PCA pump is con- trolled by law, the medication must be wasted in the presence of another nurse.

A client has been transferred to the post-anesthesia care unit from a cesarean deliv- ery. The client had spinal anesthesia for the surgery. Which of the following inter- ventions should the nurse perform at this time? 1. Assess the level of the anesthesia. 2. Encourage the client to urinate in a bedpan. 3. Provide the client with the diet of her choice. 4. Check the incision for signs of infection.

1 This answer is correct. The nurse should assess the level of anesthesia every 15 minutes while in the postanesthesia care unit.

A 4-day-old breastfeeding neonate whose birth weight was 2678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take? 1. Nothing because this is an acceptable weight loss. 2. Advise the mother to supplement feedings with formula. 3. Notify the neonatalogist of the excessive weight loss. 4. Give the baby dextrose water between breast feedings.

1 This baby has only lost 3.7% of his or her birth weight—100/2678 100% 3.7%. This is below the accepted weight loss of 5% to 10%.

The nurse is teaching a couple about fetal development. Which statement by the nurse is correct about the morula stage of development? 1. "The fertilized egg has yet to implant into the uterus." 2. "The lung fields are finally completely formed." 3. "The sex of the fetus can be clearly identified." 4. "The eye lids are unfused and begin to open and close."

1 This is a true statement. In the morula stage, about 2 to 4 days after fertilization, the fertilized egg has not yet implanted in the uterus.

A nurse, who is providing nutrition counseling to a new gravid client, advises the woman that a serving of meat is approximately equal in size to which of the following items? 1. Deck of cards. 2. VCR tape. 3. CD case. 4. Video camera.

1 This is an accurate statement. A serv- ing of meat is approximately equal to a deck of cards.

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the health care practitioner. 4. Place the client on her left side and apply oxygen by face mask.

1 This is the correct response. A fetal heart rate of 152 is normal.

The nurse is caring for a Seventh Day Adventist woman who delivered a baby boy by cesarean section. Which of the following questions should be asked regarding this woman's care? 1. "Would you like me to order a vegetarian clear liquid diet for you?" 2. "Is there anything special you will need for your Sabbath on Sunday?" 3. "Would you like to telephone your clergy to set up a date for the baptism?" 4. "Will a rabbi be performing the circumcision on your baby?"

1 This question is appropriate. Seventh Day Adventists usually follow vegetar- ian diets.

A client who is 3 days postpartum asks the nurse, "When may my husband and I begin having sexual relations again?" The nurse should encourage the couple to wait until after which of the following has occurred? 1. The client has had her six-week postpartum check-up. 2. The episiotomy has healed and the lochia has stopped. 3. The lochia has turned to pink and the vagina is no longer tender. 4. The client has had her first postpartum menstrual period.

1 This response is correct. The couple is encouraged to wait until after invo- lution is complete.

A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate? 1. "The baby received passive immunity through the placenta, plus the breast milk will also be protective." 2. "The baby should stay with relatives until the ill sibling recovers from the episode of chickenpox." 3. "Chickenpox is transmitted by contact route so careful hand washing should prevent transmission." 4. "Because chickenpox is a spirochetal illness, both the child and baby should re- ceive the appropriate medications."

1 This statement is accurate.

A 3-day-postpartum client questions why she is to receive the rubella vaccine be- fore leaving the hospital. Which of the following rationales should guide the nurse's response? 1. The client's obstetric status is optimal for receiving the vaccine. 2. The client's immune system is highly responsive during the postpartum period. 3. The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine. 4. The client's insurance company will pay for the shot if it is given during the im- mediate postpartum period.

1 This statement is correct. Because the vaccine is teratogenic, the best time to administer it is when the client is not pregnant.

Why is it essential that women of childbearing age be counseled to plan their pregnancies? 1. Much of the organogenesis occurs before the missed menstrual period. 2. Insurance companies must preapprove many prenatal care expenditures. 3. It is recommended that women be pregnant no more than 3 times during their lifetime. 4. The cardiovascular system is stressed when pregnancies are less than 2 years apart.

1 This statement is true. Organogenesis begins prior to the missed menstrual period.

The nursing management of a neonate with physiological jaundice should be di- rected toward which client care goal? 1. The baby shows no signs of kernicterus. 2. The baby does not develop erythroblastosis fetalis. 3. The baby has a bilirubin of 16 mg/dL on the day of discharge. 4. The baby spends at least 20 hours per day under phototherapy.

1 When bilirubin levels elevate to toxic levels, babies can develop kernicterus.

The nurse does not hear the baby swallow when suckling even though the baby ap- pears to be latched properly to the breast. Which of the following situations may be the reason for this observation? 1. The mother reports a pain level of 4 on a 5-point scale. 2. The baby has been suckling for over 10 minutes. 3. The mother uses the cross-cradle hold while feeding. 4. The baby lies with the chin touching the under part of the breast.

1 When the mother is anxious, overly fatigued, and/or in pain, the secretion of oxytocin is inhibited, and this, in turn, inhibits the milk ejection reflex and insufficient milk may be produced.

The nurse is reading an article that states that the maternal mortality rate in the United States in the year 2000 was 17. Which of the following statements would be an accurate interpretation of the statement? 1. There were 17 maternal deaths in the United States in 2000 per 100,000 live births. 2. There were 17 maternal deaths in the United States in 2000 per 100,000 women of childbearing age. 3. There were 17 maternal deaths in the United States in 2000 per 100,000 pregnancies. 4. There were 17 maternal deaths in the United States in 2000 per 100,000 women in the country.

1 This statement is correct. The mater- nal mortality rate is the number of deaths of women as a result of the childbearing period per 100,000 live births.

A mother is told that she should bottlefeed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply. 1. Untreated, active tuberculosis. 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 4. Chorioamnionitis. 5. Mastitis.

1 and 3 are correct. 1. A mother with active untreated TB should be separated from her baby until the mother has been on antibi- otic therapy for about 2 weeks. She can, however, pump her breast milk and have it fed to baby through an al- ternate feeding method. 2. Being hepatitis B surface antigen positive (HBSag ) is not a contraindication to breastfeeding. 3. Mothers who are HIV positive are ad- vised not to breastfeed because there is an increased risk of transmission of the virus to the infant. 4. Acute bacterial infections, such as chorioamnionitis, are not contraindica- tions to breastfeeding unless the medica- tion given to the mother is contraindi- cated. There are, however, very few antibiotics that are incompatible with breastfeeding. 5. It is recommended that a mother with mastitis continue to breastfeed. She must keep draining her breasts of milk to pre- vent the development of a breast abscess. Again, only antibiotics compatible with breastfeeding should be administered. TEST-TAKING TIP: The test taker should remember that there are very few in- stances when breastfeeding is contraindi- cated. Mothers who are hepatitis B posi- tive may breastfeed because it has not been shown that transmission rates in- crease with breastfeeding.

A nurse is working in the prenatal clinic. Which of the following findings seen in third-trimester pregnant women would the nurse consider to be within normal limits? Select all that apply. 1. Leg cramps. 2. Varicose veins. 3. Hemorrhoids. 4. Fainting spells. 5. Lordosis.

1, 2, 3, and 5 are correct. 1. Leg cramps are normal, although the client's diet should be assessed. 2. Varicose veins are normal, although client teaching may be needed. 3. Hemorrhoids are normal, although client teaching may be needed. 4. Fainting spells are not normal, although the client may feel faint when rising quickly from a lying position. 5. Lordosis, or change in the curvature of the spine, is normal, although pa- tient teaching may be needed. TEST-TAKING TIP: There are a number of physical complaints that are "normal" during pregnancy. There are interven- tions, however, that can be taught to help to alleviate some of the discomforts. The test taker should be familiar with patient education information that should be conveyed regarding the physi- cal complaints of pregnancy. For exam- ple, clients who complain of hemorrhoids should be encouraged to eat high-fiber foods and drink fluids in order to pro- duce softer stools. The softer stools should decrease the irritation of the hemorrhoids.

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal exams. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal exams. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed pe- riodically at the end of a contraction. 4. The fetal heart pattern should be as- sessed every 1 hour during the latent phase of a low-risk labor. It is not stan- dard protocol to assess every 10 minutes. 5. The nurse should assess the fetal heart before the woman ambulates. TEST-TAKING TIP: Except for invasive pro- cedures, assessment of the fetal heart pattern is the only way to evaluate the well-being of a fetus during labor. The fetal heart pattern should, therefore, be assessed whenever there is a potential for injury to the baby or to the umbilical cord. At each of the times noted in the scenario—vaginal exam, analgesic admin- istration, contraction, and ambulation— either the cord could be compressed or the baby could be compromised.

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. 1. A bulging perineum indicates pro- gression to the second stage of labor. 2. The bloody show increases as a woman enters the second stage of labor. 3. The amniotic sac can rupture at any time. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. 5. The gravida's ability to work with her la- bor is more dependent on her level of pain and her preparation for labor than on the phases and/or stages of labor. TEST-TAKING TIP: It is important that the test taker clearly understands the differ- ence between the three phases of the first stage of labor and the three stages of labor. The three phases of the first stage of labor—latent, active, and transition— are related to changes in cervical dilation and maternal behaviors. The three stages of labor are defined by specific labor pro- gressions—cervical change to full dilation (stage 1), full dilation to birth of the baby (stage 2), birth of the baby to birth of the placenta (stage 3).

A woman is planning to become pregnant. Which of the following actions should she be counseled to take before stopping birth control? Select all that apply. 1. Take a daily multivitamin. 2. See a medical doctor. 3. Drink beer instead of vodka. 4. Stop all over-the-counter medications. 5. Stop smoking cigarettes.

1, 2, and 5 are correct. 1. It is very important that women, be- fore attempting to become pregnant, begin taking daily multivitamin tablets. 2. Women who wish to become preg- nant should first see a medical doctor for a complete check-up 3. Women who wish to become pregnant should refrain from drinking any alcohol. 4. Women who wish to become pregnant should ask an obstetrician/gynecologist which over-the-counter medications should be avoided. Some—for example, acetaminophen—are safe to take, while others are not. 5. Women who wish to become preg- nant should be counseled to stop smoking. TEST-TAKING TIP: Because the embryo is very sensitive during the first trimester of pregnancy, women should be advised to be vigilant about their health even be- fore becoming pregnant. For example, folic acid, a vitamin in multivitamin tablets, helps to prevent neural tube de- fects. Women of childbearing age often fail to go for complete physical examina- tions. It is important to discover the presence of any medical illnesses before the pregnancy begins, however, so women should be counseled to have a complete physical before stopping birth control methods.

During a postpartum assessment, it is noted that a G1P1001 woman, who delivered vaginally over an intact perineum, has a cluster of hemorrhoids. Which of the follow- ing would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure.

1, 2, and 5 are correct. 1. Sitz baths do have a soothing affect for clients with hemorrhoids. 2. Clients often feel some relief when external hemorrhoids are reinserted into the rectum. 3. Oxytocin will have no affect on the hemorrhoids. 4. It is impossible to tell whether or not the hemorrhoids will change with subsequent pregnancies. 5. Topical anesthetics can provide relief from the discomfort of hemorrhoids. TEST-TAKING TIP: Hemorrhoids are vari- cose veins of the rectum. They develop as a result of the weight of the gravid uterus on the client's dependent blood vessels. In addition to the actions noted above, the client should be advised to eat high-fiber foods and drink well to pre- vent constipation.

A mother tells the nurse that, because of family history, she is afraid her baby son will develop colic. Which of the following colic management strategies should the parents be taught? Select all that apply. 1. Small, frequent feedings. 2. Prone sleep positioning. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm. 5. Maintaining a home environment that is cigarette smoke-free.

1, 3, 4, and 5 are correct. 1. Small, frequent feedings reduce the symptoms of colic in some babies. 2. The prone sleep position is not recom- mended for babies under 1 year of age. 3. Some babies' symptoms have de- creased when they were tightly swaddled. 4. This is called the colic hold. The position does help to soothe some colicky neonates. 5. Babies who live in an environment where adults smoke have a higher in- cidence of colic than babies who live in a smoke-free environment. TEST-TAKING TIP: It is essential to read each possible answer option carefully. Even though it has been shown that col- icky babies sometimes find relief when they are placed prone on a hot water bottle, it is not recommended that the babies be left in that position for sleep. It is recommended that healthy babies, whether colicky babies or not, be placed in the prone position only while awake and while supervised.

A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for devel- opmental dysplasia of the hip (DDH)? Select all that apply. 1. Grasp the baby's thighs with the thumbs on the inner thighs and forefingers on the outer thighs. 2. Gently adduct the baby's thighs. 3. Palpate the trochanter to sense changes during hip rotation. 4. Place the baby in a prone position. 5. Flex the baby's hips and knees at 90o angles.

1, 3, and 5 are correct. 1. With the baby placed flat on its back, the practitioner grasps the baby's thighs using his or her thumbs and in- dex fingers. 2. When assessing for Ortolani sign, the baby's thighs are abducted rather than adducted. 3. With the baby's hips and knees at 90o angles, the hips are abducted. With DDH, the trochanter dislocates from the acetabulum. 4. The baby is placed flat on its back. 5. Flex the baby's hips and knees at 90o angles. TEST-TAKING TIP: The test taker should review assessment skills. To assess for de- velopmental dysplasia of the hip, the Or- tolani sign, as cited in the question, is performed. The order of the steps of the procedure is (a) the nurse places the baby on its back; (b) the nurse grasps the baby's thighs with a thumb on the inner aspect and forefingers over the trochanter; (c) with the hips the knees flexed at 90o angles, the hips are abducted; (d) the nurse palpates the trochanter to assess for hip laxity. Galeazzi and Allis signs can also be assessed.

The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? 1. Meconium is filled with enteric bacteria. 2. Amniotic fluid may contain harmful viruses. 3. The high alkalinity of fetal urine is caustic to the skin. 4. The baby is high risk for infection and must be protected.

2 Amniotic fluid is a reservoir for viral diseases like HIV and hepatitis B. If the woman is infected with those viruses, the amniotic fluid will be infectious.

A breastfeeding client, G10P6408, delivered 10 minutes ago. Which of the follow- ing assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2 An assessment of the woman's fundus is the most important assessment to perform on this client.

A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BAT stores? 1. To promote melanin production in the neonatal period. 2. To provide heat production when the baby is hypothermic. 3. To protect the bony structures of the body from injury. 4. To provide calories for neonatal growth between feedings.

2 Babies do not shiver. Rather, to pro- duce heat they utilize chemical ther- mogenesis, also called nonshivering thermogenesis. BAT is metabolized during hypothermic episodes to main- tain body temperature. Unfortunately, this can lead to metabolic acidosis.

A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make? 1. Integrity of the baby's uvula. 2. Presence of maternal nipple damage. 3. Presence of neonatal tongue injury. 4. The baby's breathing pattern.

2 Babies who are tongue-tied—that is have a tight frenulum—have difficulty extending their tongues while breast- feeding. The mothers' nipples often become damaged as a result.

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must precede this assessment? 1. Place the client in the lateral recumbent position. 2. Insert an internal fetal monitor electrode. 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.

2 Before the variability can be accu- rately assessed, an internal fetal heart electrode must be applied.

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with a povidone-iodine solution after toileting.

2 Clients should be advised to change their pads at each voiding.

A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate between contractions every 60 minutes. 2. Encourage the woman to grunt during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.

2 Decelerations that mirror contrac- tions are early decelerations. These are related to head compression and are expected during transition and second stage labor.

A 36-week gestation gravid lies flat on her back. Which of the following maternal signs/symptoms would the nurse expect to observe? 1. Hypertension. 2. Dizziness. 3. Rales. 4. Chloasma.

2 Dizziness is an expected finding.

The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? 1. Teach baby care skills like diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills like pumping.

2 During the taking in phase, clients need to internalize their labor experi- ences. Discussing the labor process is appropriate for this postpartum phase.

In addition to breathing with contractions, which of the following actions can help a woman in labor to work with the pain of the first stage of labor? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

2 Effleurage is a light massage that can soothe the mother during labor.

The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatalogist as soon as possible? 1. Blood in the diaper. 2. Grunting during expiration. 3. Deep red coloring on one side of the body with pale pink on the other side. 4. Lacy and mottled appearance over the entire chest and abdomen.

2 Expiratory grunting is an indication of respiratory distress.

The nurse is assessing the laboratory report of a 40-week gestation client. Which of the following values would the nurse expect to find elevated above prepregnancy levels? 1. Glucose. 2. Fibrinogen. 3. Hematocrit. 4. Bilirubin.

2 Fibrinogen levels will be elevated slightly in a 40-week pregnant woman because coagulation factors like fib- rinogen increase to help prevent ex- cessive blood loss during delivery.

The nurse is caring for a prenatal client who states she is prone to developing ane- mia. Which of the following foods should the nurse advise the gravida is the best source of iron? 1. Raisins. 2. Hamburger. 3. Broccoli. 4. Molasses.

2 Hamburger contains the most iron.

A baby has just been admitted into the neonatal nursery. Before taking the new- born's vital signs, the nurse should warm his or her hands and the stethoscope in order to prevent heat loss resulting from which of the following? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.

2 Heat loss resulting from conduction occurs when the baby comes in con- tact with cold objects (hands or stethoscope).

A client, G2P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to make at this time? 1. Assess the woman's temperature. 2. Place a wedge under the woman's side. 3. Place a blanket roll under the woman's feet. 4. Assess the woman's pedal pulses.

2 Hypotension is a very common side effect of regional anesthesia.

A baby is just delivered. Which of the following physiological changes is of highest priority? 1. Thermoregulation. 2. Spontaneous respirations. 3. Extrauterine circulatory shift. 4. Successful feeding.

2 If a baby does not breathe, the remaining physiological transitions cannot successfully take place.

A 10-week gravid client is being seen in the prenatal clinic. For the nurse caring for this patient, providing anticipatory guidance for which of the following should be a priority? 1. Pain management during labor. 2. Methods to relieve backaches. 3. Breastfeeding positions. 4. Characteristics of the newborn.

2 It is appropriate for the nurse to pro- vide anticipatory guidance regarding methods to relieve back pain.

A couple is preparing to interview obstetric primary care providers in order to deter- mine who they will go to for care during their pregnancy and delivery. In order to make the best choice, which of the following actions should the couple perform first? 1. Take a tour of hospital delivery areas. 2. Develop a preliminary birth plan. 3. Make appointments with three or four obstetric care providers. 4. Search the internet for the malpractice histories of the providers.

2 It is best that a couple first develop a birth plan.

A nurse is caring for women from four different countries. Which of the women is most likely to request that her head be kept covered throughout her hospitalization? 1. Arabic woman. 2. Chinese woman. 3. Russian woman. 4. Greek woman.

2 It is important to inquire about the pain level of all women in labor, but especially those from the Asian culture.

The nurse is interviewing a 38-week gestation Muslim woman. Which of the fol- lowing questions would be inappropriate for the nurse to ask? 1. "Do you plan to breastfeed your baby?" 2. "What do you plan to name the baby?" 3. "Which pediatrician do you plan to use?" 4. "How do you feel about having an episiotomy?"

2 It is inappropriate to ask the Muslim client about the name for the baby.

A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be? 1. "Any powder made especially for babies should be fine." 2. "It is recommended that powder not be put on babies." 3. "There is no real difference except that many babies are allergic to cornstarch so it should not be used." 4. "As long as you only put it on the buttocks area, you can use any brand of baby powder that you like."

2 It is recommended that powders, even if advertised for the purpose, not be used on babies.

A Chinese immigrant is being seen in the prenatal clinic. When providing nutrition counseling, which of the following factors should the nurse keep in mind? 1. Many Chinese eat very little protein. 2. Many Chinese believe pregnant women should eat cold foods. 3. Many Chinese are prone to anemia. 4. Many Chinese believe strawberries can cause birth defects.

2 Many Chinese women do believe in the "hot and cold" theory of life.

An 18-week gestation client telephones the obstetrician's office stating, "I'm really scared. I think I have breast cancer. My breasts are filled with tumors." The nurse should base the response on which of the following? 1. Breast cancer is often triggered by pregnancy. 2. Nodular breast tissue is normal during pregnancy. 3. The woman is exhibiting signs of a psychotic break. 4. Anxiety attacks are especially common in the second trimester.

2 Nodular breast tissue is normal in pregnancy.

On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is 2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via face mask at 8 to 10 liters per minute. 3. Delay pushing until the baby descends further and the mother has a strong urge to push. 4. Place the woman on her side and assess her oxygen saturation.

2 Phenergan is often used as an anal- gesic potentiator.

The third stage of labor has just ended for a client who has decided to bottlefeed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

2 Prolactin will elevate sharply in the client's bloodstream.

A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first? 1. Put the baby's diapers on as tightly as possible. 2. Apply light pressure to the area with sterile gauze. 3. Call the physician who performed the surgery. 4. Assess the baby's heart rate and oxygen saturation.

2 Putting direct pressure on the site is the best way to stop the bleeding.

A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory re- ports a bilirubin assessment of 6.0 mg/dL. Which of the following would the nurse expect the neonatalogist to order for the baby at this time? 1. To be placed under phototherapy. 2. To be discharged home with the parents. 3. To be prepared for a replacement transfusion. 4. To be fed glucose water between routine feeds.

2 Since peak bilirubin levels are seen between days 3 and 5, and since the level is well within normal range, the nurse should expect that the baby will be discharged home with parents.

A woman tells the nurse that she would like suggestions for alternate vitamin C sources because she isn't very fond of citrus fruits. Which of the following sugges- tions is appropriate? 1. Barley and brown rice. 2. Strawberries and potatoes. 3. Buckwheat and lentils. 4. Wheat flour and figs.

2 Strawberries and potatoes are excellent sources of vitamin C, as are zucchini, blueberries, kiwi, green beans, green peas, and the like.

During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? 1. LOA 1 station. 2. LSP 1 station. 3. LMP 1 station. 4. LSA 1 station.

2 The LSP position is the correct answer. The fetal buttocks (S or sacrum) are facing toward the mother's left posterior (LP) and but- tocks at 1 station are 1 cm above the ischial spines.

A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min 30 sec. Fetal heart rate is in the 140s with good vari- ability and spontaneous accelerations. What should the nurse conclude when re- porting the findings to the primary health care practitioner? 1. The woman is high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3. The woman is high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.

2 The blood pressure rises dramatically.

A woman in her third trimester advises the nurse that she wishes to breastfeed her baby, "but I don't think my nipples are right." Upon examination, the nurse notes that the client has inverted nipples. Which of the following actions should the nurse take at this time? 1. Advise the client that it is unlikely that she will be able to breastfeed. 2. Refer the client to a lactation consultant for advice. 3. Call the labor room and notify them that a client with inverted nipples will be admitted. 4. Teach the woman exercises in order to evert her nipples.

2 The client should be referred to a lac- tation consultant.

The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see? 1. Oxygen saturation of 99%. 2. Hgb of 11 gm/dL. 3. Serum glucose of 140 mg/dL. 4. pH of 7.30.

2 The fetal heart should accelerate in response to scalp stimulation.

The nurse working in an outpatient obstetric office assesses four primigravid clients. Which of the client findings would the nurse highlight for the physician? 1. 17 weeks' gestation; denies feeling fetal movement. 2. 24 weeks' gestation; fundal height at the umbilicus. 3. 27 weeks' gestation; complains of excess salivation. 4. 34 weeks' gestation; complains of hemorrhoidal pain.

2 The fundal height at 24 weeks should be 4 cm above the umbilicus. The fundal height at the level of the umbilicus is expected at 20 weeks' gestation.

A 36-week gestation gravid client is complaining of dyspnea when lying flat. Which of the following is the likely clinical reason for this complaint? 1. Maternal hypertension. 2. Fundal height. 3. Hydramnios. 4. Congestive heart failure.

2 The fundal height is the likely cause of the woman's dyspnea.

An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean? 1. The fetus has become engaged. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.

2 The inlet's boundaries are: the sacral promontory and the upper margins of the ilia, ischia, and the symphysis pubis. This is the entry into the true pelvis.

A baby boy is to be circumcised by the mother's obstetrician. Which of the follow- ing actions shows that the nurse is being a patient advocate? 1. Before the procedure, the nurse prepares the sterile field for the physician. 2. The nurse refuses to unclothe the baby until the doctor orders something for pain. 3. The nurse holds the feeding immediately before the circumcision. 4. After the procedure, the nurse monitors the site for signs of bleeding.

2 The nurse is being a patient advocate since the baby is unable to ask for pain medication. The AAP has made a policy statement that pain medica- tions be used during all circumcision procedures.

A low-risk 38-week-gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucus plug." 4. "How much blood is there?"

2 The nurse is using reflection to ac- knowledge the client's concerns.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

2 The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor.

During the third stage, the following physiological changes occur. Please place the changes in chronological order. 1. Hematoma forms behind the placenta. 2. Membranes separate from the uterine wall. 3. The uterus contracts firmly. 4. The uterine surface area dramatically decreases.

2 The nurse should provide additional information to this client. Many deliv- eries are performed safely without stirrups.

A 16-year-old, G1 P0000, is being seen at her 10-week gestation visit. She tells the nurse that she felt the baby move that morning. Which of the following responses by the nurse is appropriate? 1. "That is very exciting. The baby must be very healthy." 2. "Would you please describe what you felt for me?" 3. "That is impossible. The baby is not big enough yet." 4. "Would you please let me see if I can feel the baby?"

2 The nurse should query the young woman about what she felt.

A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

2 The nurse should stabilize the base of the uterus with his or her dependent hand.

During a postpartum assessment, the nurse performs a Homan's sign. Which of the following actions does the nurse perform? 1. Taps the patellae with a reflex hammer. 2. Dorsiflexes the feet. 3. Palpates the calves and ankles. 4. Monitors the color of the extremities.

2 The nurse would dorsiflex the feet when performing Homan's sign.

During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.

2 The nurse would expect that the client would have lochia alba.

The blood of a pregnant client was initially assessed at 10 weeks' gestation and re- assessed at 38 weeks' gestation. Which of the following results would the nurse ex- pect to see? 1. Rise in hematocrit from 34% to 38%. 2. Rise in white blood cells from 5,000 cells/mm3 to 15,000 cells/mm3. 3. Rise in potassium from 3.9 mEq/ L to 5.2 mEq/ L. 4. Rise in sodium from 137 mEq/ L to 150 mEq/ L.

2 The nurse would expect to see an elevated white blood cell count.

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2 The nurse would expect to see well- approximated edges.

Which of the following exercises should be taught to a pregnant woman who com- plains of backaches? 1. Kegeling. 2. Pelvic tilting. 3. Leg lifting. 4. Crunching.

2 The pelvic tilt is an exercise that can reduce backache pain.

A woman, 6 weeks pregnant, is having a vaginal examination. Which of the follow- ing would the practitioner expect to find? 1. Thin cervical muscle. 2. An enlarged ovary. 3. Thick cervical mucus. 4. Pale pink vaginal wall.

2 The practitioner would expect to palpate an enlarged ovary.

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

2 The woman is showing expected signs of the active phase of labor.

A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down.

2 The woman should be encouraged to grunt during contractions

A client is in the second stage of labor. She falls asleep immediately after a contrac- tion. Which of the following actions should the nurse perform as a result? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

2 The woman's privacy should be main- tained while she is resting.

Which of the following statements is true about breastfeeding mothers as compared to bottlefeeding mothers? 1. Breastfeeding mothers usually involute completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.

2 There is evidence to show that women who breastfeed their babies are less likely to develop type 2 dia- betes later in life

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? 1. Fetal heart assessment after each contraction. 2. Uterus rising in the abdomen and feeling globular. 3. Rapid cervical dilation to ten centimeters. 4. Maternal complaints of intense rectal pressure.

2 These are signs of placental delivery.

The nurse is evaluating the 24-hour dairy intake of four gravid clients. Which of the following clients consumed the highest number of dairy servings during 1 day? The client who consumed: 1. 4 oz whole milk, 2 oz hard cheese, 1 cup of pudding made with milk and 2 oz cream cheese. 2. 1 cup yogurt, 8 oz chocolate milk, 1 cup cottage cheese, and 11⁄2 oz hard cheese. 3. 1⁄2 cup cottage cheese, 8 oz whole milk, 1 cup of buttermilk, and 1⁄2 oz hard cheese. 4. 1⁄2 cup frozen yogurt, 8 oz skim milk, 4 oz cream cheese, and 11⁄2 cup of cottage cheese.

2 This client consumed 32 ⁄3 servings: 1 cup yogurt 1 serving, 8 oz choco- late milk 1 serving; 1 cup cottage cheese 2⁄3 serving; and 11⁄2 oz hard cheese 1 serving.

A client, who is 7 cm dilated and 100% effaced, is breathing at a rate of 30 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers with some lightheadedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman onto her side. 4. Check the fetal heart rate.

2 This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations.

The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance the day before. The baby's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? 1. "Sometimes babies just don't deliver the way we expect them to." 2. "With all of your preparations, it must have been disappointing for you to have had a cesarean." 3. "I know you had to have surgery, but you are very lucky that your baby was born healthy." 4. "At least your husband was able to be with you when the baby was born."

2 This comment conveys sensitivity and understanding to the client.

A woman delivers a fetal demise that has lanugo covering the entire body, nails that are present on the fingers and toes, but eyes that are still fused. Prior to the death, the mother stated that she had felt quickening. Based on this information, the nurse knows that the baby is about how many weeks' gestation? 1. 15 weeks. 2. 22 weeks. 3. 29 weeks. 4. 36 weeks.

2 This fetus is about 22 weeks' gesta- tion. Nails start to develop in the first trimester, and lanugo starts to de- velop at about 20 weeks, but eyes re- main fused until about 29 weeks.

A woman is receiving patient-controlled analgesia (PCA) post-cesarean section. Which of the following must be included in the patient teaching? 1. The client should monitor how often she presses the button. 2. The client should report any feelings of nausea or itching to the nurse. 3. The family should press the button whenever they feel the woman is in pain. 4. The family should inform the nurse if the client becomes sleepy.

2 This information is correct. Clients often experience nausea and/or itching when PCA narcotics are administered.

A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

2 This information is correct. The blues usually resolve within 2 weeks of delivery.

The nurse is discussing the importance of doing Kegel exercises during the post- partum period. Which of the following should be included in the teaching plan? 1. She should repeatedly contract and relax her rectal and thigh muscles. 2. She should practice by stopping the urine flow midstream every time she voids. 3. She should get on her hands and knees whenever performing the exercises. 4. She should be taught that toned pubococcygeal muscles decrease blood loss.

2 This is a correct statement.

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

2 This is a sign of placental separation.

A client, in her third trimester, is concerned that she will not know the difference between labor contractions and normal aches and pains of pregnancy. How should the nurse respond? 1. "Don't worry. You'll know the difference when the contractions start." 2. "The contractions may feel just like a backache, but they will come and go." 3. "Contractions are a lot worse than your pregnancy aches and pains." 4. "I understand. You don't want to come to the hospital before you are in labor."

2 This is a true statement.

A woman is carrying dizygotic twins. She asks the nurse about the babies. Which of the following explanations is accurate? 1. During a period of rapid growth, the fertilized egg divided completely. 2. When the woman ovulated, she expelled two mature ova. 3. The babies share one placenta and a common chorion. 4. The babies will definitely be the same sex and have the same blood type.

2 This is a true statement. Dizygotic twins result from two mature ova that are fertilized.

A woman, 26-weeks' gestation, calls the triage nurse stating, "I'm really scared. I tried not to but I had an orgasm when we were making love. I just know that I will go into preterm labor now." Which of the following responses by the nurse is appropriate? 1. "Lie down and drink a quart of water. If you feel any back pressure at all call me back right away." 2. "Although oxytocin was responsible for your orgasm, it is very unlikely that it will stimulate preterm labor." 3. "I will inform the doctor for you. What I want you to do is to come to the hos- pital right now to be checked." 4. "The best thing for you to do right now is to take a warm shower, and then do a fetal kick count assessment."

2 This is an accurate statement.

A woman confides in the nurse that she practices pica. Which of the following alternatives could the nurse suggest to the woman? 1. Replace laundry starch with salt. 2. Replace ice with frozen fruit juice. 3. Replace soap with cream cheese. 4. Replace soil with uncooked pie crust.

2 This is an excellent suggestion. Fruit juice, although high in sugar, does contain vitamins.

The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate? 1. Irrigate the incision twice daily. 2. Monitor the incision for drainage. 3. Apply steristrips to the incision line. 4. Palpate the incision for weaknesses.

2 This is appropriate. The nurse should assess for all signs on the REEDA scale.

A client who delivered a 3900-gram baby vaginally over a right lateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

2 This is the best response. A right lat- eral episiotomy runs perpendicular to the perineum.

A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication? 1. It is administered to prevent the development of neonatal cataracts. 2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus. 3. The medicine must be administered immediately upon delivery of the baby. 4. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy.

2 This is the correct method of instilla- tion of the ophthalmic prophylaxis.

A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate? 1. "That is correct. The rice cereal takes longer for them to digest so they sleep better and longer." 2. "It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives." 3. "It is too early for rice cereal, but I would recommend giving the baby a bottle of formula at night." 4. "A better recommendation is to give apple sauce at 3 months of age and apple juice 1 month later."

2 This is the correct response.

The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement? 1. The nurse midwife saw that the mucus plug was intact. 2. The nurse midwife felt the baby rebound after being pushed. 3. The nurse midwife palpated the fetal parts through the uterine wall. 4. The nurse midwife assessed that the baby is head down.

2 This is the definition of ballottement.

On admission to the maternity unit, it is learned that a mother has smoked 2 packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following? 1. Breastfeeding is contraindicated if the mother smokes cigarettes. 2. Breastfeeding is protective for the baby and should be encouraged. 3. A 2-pack-a-day smoker should be reported to child protective services for child abuse. 4. A mother who admits to smoking cigarettes may also be abusing illicit substances.

2 This is true. Breastfeeding is protective of the baby and should be encouraged.

A breastfeeding woman, 11⁄2 months postdelivery, calls the nurse in the obstetri- cian's office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection reflex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk.

2 This is true. Oxytocin stimulates sexual orgasms and is also the hormone that stimulates the milk ejection reflex.

A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time? 1. "I am required by law to give the medicine." 2. "The medicine helps to prevent eye infections." 3. "The medicine promotes neonatal health." 4. "All babies receive the medicine at delivery."

2 This response gives the mother a brief scientific rationale for the med- ication administration.

A client enters the prenatal clinic. She states that she missed her period yesterday and used a home pregnancy test this morning. She states that the results were nega- tive, but "I still think I am pregnant." Which of the following statements would be appropriate for the nurse to make at this time? 1. "Your period is probably just irregular." 2. "We could do a blood test to check." 3. "Home pregnancy test results are very accurate." 4. "My recommendation would be to repeat the test in one week."

2 This response is correct. Serum preg- nancy tests are more sensitive than urine tests are.

The nurse takes a primipara her newborn for a feeding. The client holds the baby en face, strokes his cheek, and states that this is the first infant she has ever held. Which of the following nursing assessments is most appropriate? 1. Positive bonding and client needs little teaching. 2. Positive bonding but teaching related to infant care is needed. 3. Poor bonding and referral to a child abuse agency is essential. 4. Poor bonding but there is potential for positive mothering.

2 This response is correct. The client is showing signs of positive bonding—en face positioning and stroking of the baby's cheeks—and is in need of infor- mation on child care.

Why are obstetric clients most at high risk for cardiovascular compromise during the one hour immediately following a delivery? 1. Because the weight of the uterine body is significantly reduced. 2. Because the excess blood volume from pregnancy is circulating in the woman's periphery. 3. Because the cervix is fully dilated and the lochia flows freely. 4. Because the maternal blood pressure drops precipitously once the baby's head emerges.

2 This response is true. Once the pla- centa is birthed, the reservoir for the mother's large blood volume is gone.

The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

2 This statement is accurate. Mothers often do not feel bladder pressure af- ter delivery.

The nurse informs a postpartum woman that ibuprofen (Advil) is especially effec- tive for afterbirth pains. What is the scientific rationale for this? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen is administered in high doses.

2 This statement is correct. Ibuprofen has an antiprostaglandin effect.

A post-cesarean section, breastfeeding client, whose subjective pain level is 2/5, re- quests her as needed (prn) narcotic analgesics every 3 hours. She states, "I have de- cided to make sure that I feel as little pain from this experience as possible." Which of the following should the nurse conclude in relation to this woman's behavior? 1. The woman needs a stronger narcotic order. 2. The woman is high risk for severe constipation. 3. The woman's breast milk volume may drop while taking the medicine. 4. The woman's newborn may become addicted to the medication.

2 This statement is correct. One of the common side effects of narcotics is constipation.

A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

2 This statement is true. The best way to prevent engorgement is to feed the baby every 2 to 3 hours.

A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response? 1. "The baby does rarely open his mouth but you can see that he isn't in any distress." 2. "Babies usually breathe in and out through their noses so they can feed without choking." 3. "Everything about babies is small. It truly is amazing how everything works so well." 4. "You are right. I will report the baby's small nasal openings to the pediatrician right away."

2 This statement provides the mother with the knowledge that babies are obligate nose breathers in order to be able to suck, swallow, and breathe without choking.

The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term goal for the care of their new baby? 1. The baby will have a bath with soap every morning. 2. During a supervised play period, the baby will be placed on the tummy every day. 3. The baby will be given a pacifier after each feeding. 4. For the first month of life, the baby will sleep on its side in a crib next to the parents.

2 Tummy time, while awake and while supervised, helps to prevent plagio- cephaly and to promote growth and development.

A client states that she is a strong believer in vitamin supplements to maintain her health. The nurse advises the woman that it is recommended to refrain from con- suming excess quantities of which of the following vitamins during pregnancy? 1. Vitamin C. 2. Vitamin D. 3. Vitamin B2 (niacin). 4. Vitamin B12 (cobalamin).

2 Vitamin D supplementation can be harmful during pregnancy.

A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal deliv- ery, questions the nurse because her baby's face is "purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following? 1. Petechiae are indicative of severe bacterial infections. 2. Rapid deliveries can injure the neonatal presenting part. 3. Petechiae are characteristic of the normal newborn rash. 4. The injuries are a sign that the child has been abused.

2 When neonates speed through the birth canal during rapid deliveries, the presenting parts become bruised. The bruising often takes the form of petechial hemorrhages.

A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? 1. Hemolysis of neonatal red blood cells by the maternal antibodies. 2. Physiological destruction of fetal red blood cells during the extrauterine period. 3. Pathological liver function resulting from hypoxemia during the birthing process. 4. Delayed meconium excretion resulting in the production of direct bilirubin.

2 With lung oxygenation, the neonate no longer needs large numbers of red blood cells. As a result, excess red blood cells (RBCs) are destroyed. Jaundice often results on days 2 to 4.

One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this di- agnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.

2, 3, and 4 are correct. 1. Although clients should drink fluids, this is not a goal related to the identified nursing diagnosis. 2. An important goal is that the woman's WBC will remain stable. 3. An important goal is that the woman's temperature will remain normal. 4. An important goal is that the woman's lochia will smell normal. 5. Sitz baths are not given to prevent infec- tions. They do help to soothe the pain and/or the inflammation associated with episiotomies and hemorrhoids. TEST-TAKING TIP: The WBC is elevated during late pregnancy, delivery, and early postpartum, but if it rises very rapidly, the rise is often associated with a bacter- ial infection. The lochia usually smells "musty." When a client has endometritis, however, the lochia smells "foul." A tem- perature above 100.4oF after the first 24 hours postpartum is indicative of a puerperal infection.

A third-trimester client is being seen for routine prenatal care. Which of the fol- lowing assessments will the nurse perform during the visit? Select all that apply. 1. Blood glucose. 2. Blood pressure. 3. Fetal heart rate. 4. Urine protein. 5. Pelvic ultrasound.

2, 3, and 4 are correct. 1. Urine glucose is performed at each visit, not the blood glucose. 2. The blood pressure is assessed at each prenatal visit. 3. The fetal heart rate is assessed at each prenatal visit. Depending on the equipment available, it will be assessed mechanically via Doppler or manually via fetoscope. The fetal heart is audible via Doppler manyweeks before it is audible via fetoscope. 4. Urine protein is performed at each prenatal visit. 5. Ultrasounds are only performed when needed. TEST-TAKING TIP: The test taker must read the question carefully. Although urine glucose assessments are done at each visit, blood glucoses are assessed only intermittently during the pregnancy. Similarly, although ultrasound assess- ments may be ordered intermittently during a pregnancy, they are certainly not done at every prenatal visit. As a matter of fact, there is no absolute mandate that a sonogram must be done at all during a pregnancy.

A client asks the nurse what was meant when the physician told her she had a posi- tive Chadwick's sign. Which of the following information about the finding would be appropriate for the nurse to convey at this time? 1. "It is a purplish stretch mark on your abdomen." 2. "It means that you are having heart palpitations." 3. "It is a bluish coloration of your cervix and vagina." 4. "It means the doctor heard abnormal sounds when you breathed in."

3 A positive Chadwick's sign means that the client's cervix and vagina are a bluish color. It is a probable sign of pregnancy.

A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the health care practitioner? 1. Birth weight. 2. Head and chest circumferences. 3. Ortolani sign. 4. Supernumerary nipples.

3 A positive Ortolani sign indicates a likely developmental dysplasia of the hip. In Ortolani sign, the thighs are gently abducted. If the trochanter dis- places from the acetabulum, the result is positive and indicative of develop- mental dysplasia of the hip.

The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full-term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. Variable baseline of 140 with V-shaped decelerations to 120 unrelated to contractions. 2. Variable baseline of 140 with decelerations to 100 that mirror each of the contractions. 3. Flat baseline of 140 with decelerations to 120 that return to baseline after the end of the contractions. 4. Flat baseline of 140 with no obvious decelerations or accelerations.

3 Analgesics are CNS depressants. The variability of the fetal heart rate, therefore, will be decreased.

The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatalogist? 1. 1-day-old, HR 110 beats per minute in deep sleep. 2. 2-day-old, T 97.7oF, slightly jaundiced. 3. 3-day-old, breastfeeding every 4 hours, jittery. 4. 4-day-old, crying, papular rash on an erythematous base.

3 Babies who breastfeed fewer than 8 times a day are not receiving ade- quate nutrition. Jitters are indicative of hypoglycemia.

A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? 1. "Babies have a poorly developed sense of smell until they are 2 months old." 2. "Babies can taste only salty and sour substances at birth." 3. "Babies are especially sensitive to being touched and cuddled." 4. "Babies are nearsighted with blurry vision until they are about 3 months of age."

3 Babies' sense of touch is considered to be the most well-developed sense.

A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that further teaching by the nurse is needed? 1. The first hepatitis B injection is given by 1 month of age. 2. The first polio injection will be given at 2 months of age. 3. The MMR (measles, mumps, and rubella) immunization should be administered before the first birthday. 4. Three DTaP (diphtheria, tetanus, and acellular pertussis) shots will be given during the first year of life.

3 Because the baby has received passive immunity from the mother, the MMR is not given until the second year of life.

A woman states that she is going to bottlefeed her baby because, "I hate milk and I know that to make good breast milk I will have to drink milk." The nurse's re- sponse about producing high-quality breast milk should be based on which of the following? 1. The mother must drink at least 3 glasses of milk per day in order to absorb suf- ficient quantities of calcium. 2. The mother should consume at least 1 glass of milk per day but should also con- sume other dairy products like cheese. 3. The mother can consume a variety of good calcium sources like broccoli and fish with bones as well as dairy products. 4. The mother must monitor her protein intake more than her calcium intake because the baby needs the protein for growth.

3 Dairy foods provide protein and other nutrients, including the important mineral calcium. The calcium can, however, be obtained from a number of other foods, such as broccoli and fish with bones.

A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Inform the neonate's pediatrician.

3 Diaphoresis is normal during the postpartum period.

During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.

3 During extension, the baby's head is birthed.

A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection? 1. Hepatitis B immune globulin in a second syringe. 2. Sterile water to dilute the vaccine before injecting. 3. Epinephrine in case of severe allergic reactions. 4. Oral syringe since the vaccine is given by mouth.

3 Epinephrine should be available whenever vaccinations are adminis- tered in case the recipient should develop anaphylactic symptoms.

A nurse midwife has advised a 39-week gestation gravid to take evening primrose oil 2500 mg daily as a complementary therapy. This suggestion was made because evening primrose has been shown to perform which of the following actions? 1. Relieve back strain. 2. Improve development of colostrum. 3. Ripen the cervix. 4. Reduce the incidence of hemorrhoids.

3 Evening primrose converts to a prostaglandin substance in the body. Prostaglandins are responsible for readying the cervix for dilation.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the client who makes which of the following statements needs additional teaching? 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucus plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina."

3 Expelling the mucus plug is not suffi- cient reason to go to the hospital to be assessed.

The following four changes occur during pregnancy. Which of them usually in- creases the father's interest and involvement in the pregnancy? 1. Learning the results of the pregnancy test. 2. Attending childbirth education classes. 3. Hearing the fetal heartbeat. 4. Meeting the obstetrician or midwife.

3 Hearing the fetal heart beat often increases fathers' interests in their partners' pregnancies.

The glucose challenge screening test is performed at or after 24 weeks' gestation to assess for the maternal physiological response to which of the following pregnancy hormones? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

3 Human placental lactogen (hPL) is an insulin antagonist.

The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included? 1. Clean the eyes from outer canthus to inner canthus. 2. Cleanse the ear canals with a cotton swab. 3. Assemble all supplies before beginning the bath. 4. Check temperature of the bath water with fingertips.

3 If items must be obtained while the bath is being given, the baby may be- come hypothermic from evaporation resulting from exposure to the air when wet.

A bottlefeeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that further teaching is needed? 1. The woman gently strokes and pats her baby's back. 2. The woman positions the baby face down on her lap. 3. The woman waits to burp the baby until the baby's feeding is complete. 4. The woman states that a small amount of regurgitated formula is acceptable.

3 In the first few weeks of life, it is im- portant to burp babies frequently throughout feedings. Bottlefed babies often take in a great deal of air. Babies who burp only at the end of the feed often burp up large quantities of for- mula. Further teaching is needed.

A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions like she wants to bottlefeed. Which of the following is a likely explanation for the woman's behavior? 1. She has decided not to breastfeed. 2. She thinks she must give formula before the breast. 3. She believes that colostrum is bad for the baby. 4. She thinks that she should bottlefeed.

3 It is a common belief among the women of many cultures, including Mexican, some Asian, and some Native Americans, that colostrum is bad for babies.

A 20-year-old client states that the at-home pregnancy test that she took this morn- ing was positive. Which of the following comments by the nurse is appropriate at this time? 1. "Congratulations, you and your family must be so happy." 2. "Have you told the baby's father yet?" 3. "How do you feel about the results?" 4. "Please tell me when your last menstrual period was."

3 It is important for the nurse to ask the young woman how she feels about being pregnant. She may decide not to continue with the pregnancy.

A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? 1. If their baby is sleeping soundly, they should not awaken the baby for a feeding. 2. If they take their baby outside, they should put sunscreen on the baby. 3. They should purchase liquid acetaminophen to be used when ordered by the pe- diatrician. 4. They should notify their pediatrician when the umbilical cord falls off.

3 Liquid acetaminophen should be available in the home, but it should not be administered until the parent speaks to the pediatrician.

A client is in the 10th week of her pregnancy. Which of the following symptoms would the nurse expect the client to exhibit? 1. Backache. 2. Dyspnea. 3. Fatigue. 4. Diarrhea.

3 Most women complain of fatigue during the first trimester.

Four newborns are in the neonatal nursery. Which of the babies should the nurse report to the neonatalogist? 1. 16-hour-old baby who has yet to pass meconium. 2. 16-hour-old baby whose blood glucose is 50 mg/dL. 3. 2-day-old baby who is breathing irregularly at 70 breaths per minute. 4. 2-day-old baby who is excreting a milky discharge from both nipples.

3 Normal neonatal breathing is irregu- lar at 30 to 60 breaths per minute. This baby is tachypneic.

The nurse is caring for an Orthodox Jewish woman in labor. It would be appropri- ate for the nurse to include which of the following in the plan of care? 1. Encourage the father to hold his partner's hand during labor. 2. Ask the woman if she would like to speak with her priest. 3. Provide the woman with a long-sleeved hospital gown. 4. Place an order for the woman's postpartum vegetarian diet

3 Observant Jewish women are ex- pected to have their elbows covered at all times. A long-sleeved gown, there- fore, should be provided for them.

A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into? 1. Fetal position. 2. Lithotomy position. 3. Trendelenburg position. 4. Lateral recumbent position.

3 Once the woman has a strong urge to push, then she should be encouraged to push against an open glottis in or- der to birth the baby.

A breastfeeding mother states that she has sore nipples. In response to the com- plaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate infant positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

3 Rotating positions at feedings is one action that can help to minimize the severity of sore nipples.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

3 Since the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ.

A multipara, LOA, station 3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. "Epidurals do not work well when the pain level is above level 5." 2. "I will contact the doctor to get an order for an epidural right away." 3. "The baby is going to be born very soon. It is really too late for an epidural." 4. "I will check the fetal heart rate. You can have an epidural if it is over 120."

3 Since this is a normal finding, the nurse should continue to provide la- bor support and encouragement.

A pregnant woman is discussing positioning and the use of leg stirrups for delivery with a labor nurse. In which of the following instances should the nurse provide further information to the client? 1. When the client states, "I am glad that deliveries can take place in a variety of places, including a Jacuzzi bathtub." 2. When the client says, "I heard that for doctors to deliver babies safely, it is essential to have the mother's legs up in stirrups." 3. When the client says, "During difficult deliveries it is sometimes necessary to put a woman's legs up in stirrups." 4. When the client states, "I heard that midwives often deliver their patients either in the side-lying or squatting position."

3 Since this woman is a multipara, the position is LOA and the station is 3, this is an accurate statement.

Which of the following responses is the primary rationale for providing general information as well as breathing and relaxation exercises in childbirth education classes? 1. Mothers who are doing breathing exercises during labor will refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the fear- tension-pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

3 Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle.

A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the infor- mation? 1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide. 2. The mother covers the glans with antifungal ointment after rinsing off any discharge. 3. The mother squeezes soapy water from the wash cloth over the glans. 4. The mother replaces the dry sterile dressing before putting on the diaper.

3 Squeezing soapy water over the penis cleanses the area without irritating the site and causing the site to bleed.

A mother calls the nurse to her room because "My baby's eyes are bleeding." The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time? 1. Notify the pediatrician immediately and report the finding. 2. Notify the social worker about the probable maternal abuse. 3. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear. 4. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and con- dition of the retina in each eye.

3 Subconjunctival hemorrhages are a normal finding and are not pathologi- cal. They will disappear over time. Explaining this to the mother is the appropriate action.

The nurse notes that a newborn, who is 5 minutes old, exhibits the following char- acteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is? 1. 6 2. 7 3. 8 4. 9

3 The baby's Apgar is 8.

A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

3 The blood pressure should be assessed before administering Methergine.

A primipara, 4 hours postpartum, requests that the nurse diaper her baby after a feeding because, "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is ex- hibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

3 The client is exhibiting normal post- partum behavior.

The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider? 1. White blood cells—12,500 cells/mm3. 2. Red blood cells—4,500,000 cells/mm3. 3. Hematocrit—26%. 4. Hemoglobin—11 g/dL

3 The client's hematocrit is well below normal. This value should be reported to the client's health care provider.

A pregnant woman informs the nurse that her last normal menstrual period was on September 20, 2006. Using Nagele's rule, the nurse calculates the client's estimated date of delivery as: 1. May 30, 2007. 2. June 20, 2007. 3. June 27, 2007. 4. July 3, 2007.

3 The estimated date of delivery is June 27, 2007.

When performing Leopold's maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Where should the nurse place a fetoscope best to hear the fetal heart beat? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

3 The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question.

A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord? 1. Cleanse it with hydrogen peroxide if it starts to smell. 2. Remove it with sterile tweezers at one week of age. 3. Call the doctor if greenish drainage appears. 4. Cover it with sterile dressings until it falls off.

3 The green drainage may be a sign of infection. The cord should become dried and shriveled.

A nurse is providing diet counseling to a new prenatal client. Which of the following dairy products should the client be advised to avoid eating during the pregnancy? 1. Vanilla yogurt. 2. Parmesan cheese. 3. Gorgonzola cheese. 4. Chocolate milk.

3 The intake of gorgonzola cheese should be discouraged during preg- nancy.

The nurse is providing acupressure to provide pain relief to a woman in labor. Where is the best location for the acupressure to be applied? 1. On the malleolus of the wrist. 2. Above the patella of the knee. 3. On the medial aspect of the lower leg. 4. Below the medial epicondyle of the elbow.

3 The medial surface of the lower leg has been shown to lessen the pain of labor.

A 2-day postpartum mother, G2P2002, states that her 2-year-old daughter at home is very excited about taking "my baby sister" home. Which of the following is an appropriate response by the nurse? 1. "It's always nice when siblings are excited to have the babies go home." 2. "Your daughter is very advanced for her age. She must speak very well." 3. "Your daughter is likely to become very jealous of the new baby." 4. "Older sisters can be very helpful. They love to play mother."

3 The nurse should forewarn the mother about the likelihood of the 2-year-old's jealousy.

On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was as- sessed at 11.0 gm/dL, and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? 1. Hgb 12.5 gm/dL; Hct 37%. 2. Hgb 11.0 gm/dL; Hct 33%. 3. Hgb 10.5 gm/dL; Hct 31%. 4. Hgb 9.0 gm/dL; Hct 27%.

3 The nurse would expect these values—a slight decrease in both hemoglobin and hematocrit values.

A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? 1. Skim milk. 2. Ginger ale. 3. Orange juice. 4. Chamomile tea.

3 The nurse would recommend that the iron be taken with orange juice be- cause ascorbic acid, which is in orange juice, promotes the absorption of iron into the body.

An ultrasound of a fetus' heart shows that normal fetal circulation is occurring. Which of the following statements should the nurse interpret as correct in relation to the fetal circulation? 1. The foramen ovale is a hole between the ventricles. 2. The umbilical vein contains oxygen-poor blood. 3. The right atrium contains both oxygen-rich and oxygen-poor blood. 4. The ductus venosus lies between the aorta and pulmonary artery.

3 The right atrium does contain both oxygen-rich and oxygen-poor blood.

After nutrition counseling, a woman, G3 P1101, proclaims that she certainly can't eat any strawberries during her pregnancy. Which of the following is the likely reason for this statement? 1. The woman is allergic to strawberries. 2. Strawberries have been shown to cause birth defects. 3. The woman believes in old wives' tales. 4. The premature baby died because the woman ate strawberries.

3 The woman believes in old wives' tales.

The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.

3 The woman should turn, cough, and deep breathe every 2 hours.

A woman provides the nurse with the following obstetrical history: Delivered a son, now 7 years old, at 28 weeks' gestation; delivered a daughter, now 5 years old, at 39 weeks' gestation; had a miscarriage 3 years ago, and had a first-trimester abortion 2 years ago. She is currently pregnant. Which of the following portrays an accurate picture of this woman's gravidity and parity? 1. G4 P2121. 2. G4 P1212. 3. G5 P1122. 4. G5 P2211.

3 This accurately reflects this woman's gravidity and parity—G5P1122.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant? 1. Assess client's fundal height. 2. Teach client how to massage her fundus. 3. Take the client's vital signs. 4. Document quantity of lochia in the chart.

3 This action can be delegated to a nursing assistant. Once the vital signs are checked, the nursing assistant can report the results to the nurse for his or her interpretation.

A client, G2P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.

3 This action is very important. If the legs are removed from the stirrups one at a time, the woman is at high risk for back and abdominal injuries.

In which of the following situations would it be appropriate for the father to place the baby in the en face position? 1. The baby is asleep with little to no eye movement, regular breathing. 2. The baby is asleep with rapid eye movement, irregular breathing. 3. The baby is awake, looking intently at an object, irregular breathing. 4. The baby is awake, placing hands in the mouth, irregular breathing.

3 This baby is in the quiet alert behav- ioral state. Placing the baby en face will foster bonding between the father and baby.

The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terri- ble. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Posttrauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

3 This diagnosis is appropriate. This client is showing signs of postpartum blues; one of the main reasons for this problem is related to the hormonal changes that occur after delivery.

The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? 1. When the cheek of the baby is touched, the newborn turns toward the side that is touched. 2. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. 3. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. 4. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

3 This is a description of the Moro reflex. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex.

A 34-week gestation woman calls the obstetric office stating, "Since last night I have had three nosebleeds." Which of the following responses by the nurse is appropriate? 1. "You should see the doctor to make sure you are not becoming severely anemic." 2. "Do you have a temperature?" 3. "One of the hormones of pregnancy makes the nasal passages prone to bleeds." 4. "Do you use any inhaled drugs?"

3 This is an accurate statement. Hor- monal changes in pregnancy make the nasal passages prone to bleeds.

A client makes the following statement after finding out that her pregnancy test is positive, "This is not a good time. I am in college and the baby will be due during final exams!" Which of the following responses by the nurse would be most appro- priate at this time? 1. "I'm absolutely positive that everything will turn out all right." 2. "I suggest that you e-mail your professors to set up an alternate plan." 3. "It sounds like you're feeling a little overwhelmed right now." 4. "You and the baby's father will find a way to get through the pregnancy."

3 This is the best comment. It acknowl- edges the concerns that the client is having.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

3 This is the most important goal during the immediate postdelivery period.

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap."

3 This response indicates that the labor contractions are increasing in intensity.

The day after delivery a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong, "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.

3 This response is correct. Polyuria is normal.

A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done some- thing terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, I bet you have a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in for an assessment?"

3 This response is correct. The woman should be encouraged to use a lubri- cating jelly or oil.

The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? 1. The woman performs the procedure twice a day. 2. The woman sits in warm tap water for ten minutes. 3. The woman sprays her perineum from front to back. 4. The woman mixes tap water with hydrogen peroxide.

3 This statement is accurate.

The nurse is caring for a nulliparous client who attended Lamaze childbirth educa- tion classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage.

3, 4, and 5 are correct. 1. Hypnotic suggestion is usually not in- cluded in childbirth education based on the Lamaze method. 2. Rhythmic chanting is usually not in- cluded in childbirth education based on the Lamaze method. 3. Muscle relaxation is an integral part of Lamaze childbirth education. 4. Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5. Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth education. TEST-TAKING TIP: The test taker may have expected to find breathing techniques included in the question related to Lamaze childbirth education. Although breathing techniques are taught, there are a number of other techniques and principles that couples learn in Lamaze classes. The test taker should be familiar with all aspects of childbirth education.

It has just been discovered that a newborn is missing from the maternity unit. The nursing staff should be watchful for which of the following individuals? 1. A middle-aged male. 2. An underweight female. 3. Pro-life advocate. 4. Visitor of the same race.

4 Abductors usually choose newborns of their same race.

A newly delivered mother states, "I have not had any alcohol since I decided to be- come pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change." Which of the following is the best re- sponse by the nurse? 1. "I understand that being good for so many months can become very frustrating." 2. "Even if you bottlefeed the baby, you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health." 3. "Alcohol can be consumed at any time while you are breastfeeding." 4. "You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again."

4 Alcohol is found in the breast milk in exactly the same concentration as in the mother's blood. Alcohol consump- tion is not, however, incompatible with breastfeeding. The woman should breastfeed immediately before consuming a drink and then wait 1 to 2 hours to metabolize the drink be- fore feeding again. If she decides to have more than one drink ,she can pump and dump her milk for a feed- ing or two.

A Muslim woman requests something to eat after the delivery of her baby. Which of the following meals would be most appropriate for the nurse to give her? 1. Ham sandwich. 2. Bacon and eggs. 3. Spaghetti with sausage. 4. Chicken and dumplings.

4 Although this is not a traditional Muslim dish, the foods are allowable by Muslim tradition.

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and 3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Assess for signs of rectal pressure.

4 Assessing for rectal pressure is appropriate at this time.

The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed? 1. The client states that the pain has decreased. 2. The nurse hears the baby swallow after each suck. 3. The baby's jaws move up and down once every second. 4. The baby's cheeks move in and out with each suck.

4 Babies whose cheeks move in and out during feeds are attempting to use negative pressure to extract the milk from the breasts. This action is not an indicator of breastfeeding success.

A G2P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is as- sessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider.

4 Because of the heavy lochia, the nurse should notify the woman's health care provider.

The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? 1. 1⁄2 cup raw celery dipped in 1 ounce cream cheese. 2. 8 ounce yogurt mixed with 1 medium banana. 3. 12 ounce strawberry milk shake. 4. 11⁄2 cup raw broccoli.

4 Broccoli is very high in vitamin A and also contains iron.

Which short-term goal is appropriate for a full-term, breastfeeding neonate? 1. The baby will regain birth weight by 4 weeks of age. 2. The baby will sleep through the night by 4 weeks of age. 3. The baby will stool every 3 to 4 hours by 1 week of age. 4. The baby will urinate 6 to 10 times per day by 1 week of age.

4 By 1 week of age, breastfed babies should be urinating at least 6 times in every 24-hour period.

A primigravida is pushing with contractions. The nurse notes that the woman's per- ineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? 1. Report the findings to the woman's health care practitioner. 2. Immediately assess the woman's pulse and blood pressure. 3. Provide encouragement during each contraction. 4. Place the client on her side with oxygen via face mask.

4 By taking a slow, cleansing breath before pushing, the woman is waiting until the contraction builds to its peak. Her pushes will be more effec- tive at this point in the contraction.

A client is 15 weeks pregnant. She calls the obstetric office to request a medication for a headache. The nurse answers the telephone. Which of the following is the nurse's best response? 1. "Because the organ systems in the baby are developing right now, it is risky to take medicine." 2. "You can take any of the over-the-counter medications because they are all safe in pregnancy." 3. "The physician will prescribe a category "X" medication for you." 4. "You can take acetaminophen because it is a category "B" medicine."

4 Category "B" medications have been shown to be safe to take throughout pregnancy.

A client informs the nurse that she is "very constipated." Which of the following foods would be best for the nurse to recommend to the client? 1. Bananas. 2. Rice. 3. Yogurt. 4. Celery.

4 Celery is an excellent food to reverse constipation.

The mother notes that her baby has a "bulge" on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following? 1. Molding of the baby's skull so that the baby could fit through her pelvis. 2. Swelling of the tissues of the baby's head from the pressure of her pushing. 3. The position that the baby took in her pelvis during the last trimester of her pregnancy. 4. Small blood vessels that broke under the baby's scalp during birth.

4 Cephalhematomas are subcutaneous swellings of accumulated blood from the trauma of delivery. The bulges may be one sided or bilateral and the swellings do not cross suture lines.

The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that more teaching is needed when the mother states that which of the following diseases is included in the screening test? 1. Hypothyroidism. 2. Sickle cell anemia. 3. Galactosemia. 4. Cerebral palsy.

4 Cerebral palsy (CP) is a disorder characterized by motor dysfunction resulting from a nonprogressive injury to brain tissue. The injury usually oc- curs during labor, delivery, or shortly after delivery. Physical examination is required to diagnose CP. Blood screening is not an appropriate means of diagnosis.

A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement." 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

4 Consuming fluids and fiber and exer- cising all help clients to reestablish normal bowel function.

The nurse takes the history of a client, G2 P1001, at her first prenatal visit. Which of the following statements would indicate that the client should be referred to a genetic counselor? 1. "My first child has cerebral palsy." 2. "My first child has hypertension." 3. "My first child has asthma." 4. "My first child has cystic fibrosis."

4 Cystic fibrosis is an autosomal reces- sive genetic disease so the client with a history of cystic fibrosis should be referred to a genetic counselor.

A woman asks the nurse about consuming herbal supplements during pregnancy. Which of the following responses is appropriate? 1. Herbals are natural substances, so they are safely ingested during pregnancy. 2. It is safe to take licorice and cat's claw, but no other herbs are safe. 3. A federal commission has established the safety of herbals during pregnancy. 4. The woman should discuss everything she eats with a health care practitioner.

4 Every woman should advise her health care practitioner of what she is con- suming, including food, medicines, herbals, and all other substances.

A 2-day-old, exclusively breastfed baby is to be discharged home. Under what con- ditions should the nurse teach the parents to call the pediatrician? 1. If the baby feeds 8 to 12 times each day. 2. If the baby urinates 6 to 10 times each day. 3. If the baby has stools that are watery and bright yellow. 4. If the baby has eyes and skin that are tinged yellow.

4 If the baby has yellow sclerae, the baby is exhibiting signs of jaundice and the pediatrician should be contacted.

The nurse observes a healthy woman of African descent expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time? 1. Report the abusive behavior to the social worker. 2. Advise the mother that her action is potentially dangerous. 3. Observe the mother for other signs of irrational behavior. 4. Ask the woman about other cultural traditions.

4 In Africa, breast milk is often ex- pressed into babies' eyes to prevent neonatal eye infections. Asking the woman about other cultural traditions is appropriate.

A woman who has just delivered has decided to bottlefeed her full-term baby. Which of the following should be included in the patient teaching? 1. The baby's stools will appear bright yellow and will usually be loose. 2. The bottle nipples should be enlarged to ease the baby's suckling. 3. It is best to heat the baby's bottle in the microwave before feeding. 4. It is important to hold the bottle to keep the nipple filled with formula.

4 In order to minimize the ingestion of large quantities of air, the bottle should be held so that the nipple is al- ways filled with formula.

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the fol- lowing times? 1. After every contraction. 2. For 10 minutes every half hour. 3. Periodically during the peak of contractions. 4. For 1 minute immediately after contractions.

4 Intermittent auscultation should be performed for 1 full minute after con- tractions end.

A patient, G2P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2oF. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.

4 It is likely that this client is dehy- drated. She should be advised to drink fluids.

A 37-week gravid client states that she noticed a "white liquid" leaking from her breasts during a recent shower. Which of the following nursing responses is appro- priate at this time? 1. Advise the woman that she may have a galactocele. 2. Encourage the woman to pump her breasts to stimulate an adequate milk supply. 3. Assess the liquid because a breast discharge is diagnostic of a mammary infection. 4. Reassure the mother that this is normal in the third trimester.

4 It is normal for colostrum to be expressed late in pregnancy.

A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions should the RN perform rather than delegating it to the CNA? 1. Bathe and weigh a 1-hour-old baby. 2. Take the apical heart rate and respirations of a 4-hour-old baby. 3. Obtain a stool sample from a 1-day-old baby. 4. Provide discharge teaching to the mother of a 4-day-old baby.

4 It is the registered nurse's responsi- bility to provide discharge teaching to clients. Only the RN knows the scientific rationales as well as the knowledge of teaching-learning prin- ciples necessary to provide accurate information and answer questions appropriately.

The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins? 1. Vitamin A. 2. Vitamin B12. 3. Vitamin C. 4. Vitamin D.

4 Many babies are vitamin D deficient because of the recommendation that they be kept out of direct sunlight to protect their skin from sunburn. For this reason, supplementation with vi- tamin D is recommended.

A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

4 Many mothers who consume approxi- mately the same number of calories while breastfeeding as they did when they were pregnant do lose weight while breastfeeding.

To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery? 1. Assists the woman into a squatting position. 2. Advises the woman to push only when she feels the urge. 3. Encourages the woman to push slowly and steadily. 4. Massages the perineum with mineral oil.

4 Massaging of the perineum with min- eral oil does help to reduce perineal tearing.

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system.

4 Moderate variability is indicative of fetal health.

A nurse is teaching a class of pregnant couples the most therapeutic breathing tech- nique for the latent phase of labor. Which of the following techniques did the nurse teach? 1. Alternately panting and blowing. 2. Rapid, deep breathing. 3. Grunting and pushing with contractions. 4. Slow chest breathing.

4 Most women find slow chest breath- ing effective during the latent phase.

The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatalogist? 1. The eyes cross and uncross when they are open. 2. The ears are positioned in alignment with the inner and outer canthus of the eyes. 3. Axillae and femoral folds of the baby are covered with a white cheesy substance. 4. The nostrils flare whenever the baby inhales.

4 Nasal flaring is a symptom of respira- tory distress.

A physician writes in a breastfeeding mother's chart, "Ampicillin 500 mg q 6 h po. Baby should be bottlefed until medication is discontinued." What should be the nurse's next action? 1. Follow the order as written. 2. Call the doctor and question the order. 3. Follow the antibiotic order but ignore the order to bottlefeed the baby. 4. Refer to a text to see whether the antibiotic is safe while breastfeeding.

4 Once the reference has been consulted, the nurse will have factual information to relay to the physician—specifically that ampicillin is compatible with breastfeeding. A call to the doctor would then be appropriate.

A nurse has identified the following nursing diagnosis for a prenatal client: Altered nutrition: less than body requirements related to poor folic acid intake. Which of the following foods should the nurse suggest the client consume? 1. Potatoes and grapes. 2. Cranberries and squash. 3. Apples and corn. 4. Oranges and spinach.

4 Oranges and spinach are excellent folic acid sources.

The nurse is providing anticipatory guidance to a woman in her second trimester regarding signs/symptoms that she might experience in the coming weeks. Which of the following comments by the client indicates that further teaching is needed? 1. "During the third trimester I may experience frequent urination." 2. "During the third trimester I may experience heartburn." 3. "During the third trimester I may experience back pain." 4. "During the third trimester I may experience persistent headache."

4 Persistent headache should not be seen in pregnant women.

A nurse, when providing discharge teaching to parents, emphasizes actions to prevent plagiocephaly and to promote gross motor development in their full-term newborn. Which of the following actions should the nurse advise the parents to take? 1. Breastfeed the baby frequently. 2. Make sure the baby receives vaccinations at recommended intervals. 3. Change the diapers regularly. 4. Minimize supine positioning during supervised play periods.

4 Prolonged supine posturing by babies can result in flattening of the backs of babies' heads (plagiocephaly). Being placed in the prone position while awake allows babies to practice gross motor skills like rolling over.

A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based? 1. Boys should be circumcised in order for them to establish a positive self-image. 2. Boys should not be circumcised because there is no medical rationale for the procedure. 3. Experts from the Centers for Disease Control and Prevention argue that circumcision is desirable. 4. A statement from the American Academy of Pediatrics asserts that circumcision is optional.

4 The AAP, although acknowledging that there are some advantages to cir- cumcision, states that there is not enough evidence to suggest that all baby boys be circumcised.

The parents and their full-term, breastfed neonate were discharged from the hospi- tal. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? 1. The parents weigh their baby's diapers. 2. The parents measure the baby's intake. 3. The parents give one bottle of formula every day. 4. The parents take the baby to see the pediatrician.

4 The baby should be seen by the pedi- atrician.

The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning."

4 The baby's head is almost crowning.

A client asks the nurse, "Could you explain how the baby's blood and my blood sep- arate at delivery?" Which of the following responses is appropriate for the nurse to make? 1. "When the placenta is born, the circulatory systems separate." 2. "When the doctor clamps the cord, the blood stops mixing." 3. "The separation happens after the baby takes the first breath. The baby's oxygen no longer has to come from you." 4. "The blood actually never mixes. Your blood supply and the baby's blood supply are completely separate."

4 The blood supplies are completely separate.

ne hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and 1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now 1. 2. 3. 4. 9 cm dilated, 70% effaced, and 2 station. 9 cm dilated, 80% effaced, and 3 station. 10 cm dilated, 90% effaced, and 4 station. 10 cm dilated, 100% effaced, and 5 station.

4 The cervix is fully dilated and fully ef- faced and the baby is low enough to be seen through the vaginal introitus.

The nurse enters a Latin woman's postpartum room and notes that her neonate is wearing a hat and is covered in three blankets. The room temperature is 70oF. The nurse's action should be based on which of the following? 1. Overdressing babies is common in some cultures and should be ignored. 2. The mother has dressed the baby appropriately for the room temperature. 3. The nurse should drop the room temperature since the baby is overdressed. 4. Overheating is dangerous for neonates and the extra clothing should be removed.

4 The clothing should be removed and the mother should be educated about SIDS and about the correlation be- tween overheating and SIDS.

A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe? 1. Suction the nostrils before suctioning the mouth. 2. Make sure to suction the back of the throat. 3. Insert the syringe before compressing the bulb. 4. Dispose of the drainage in a tissue or a cloth.

4 The drainage should be evaluated by the nurse. The drainage, therefore, should be disposed of in a tissue or cloth.

A nurse describes a client's contraction pattern as: frequency every 3 min and dura- tion 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period.

4 The frequency and duration of this contraction pattern is every 3 minutes lasting 60 seconds.

The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

4 The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3.

A client informs the nurse that she intends to bottlefeed her baby. Which of the following actions should the nurse encourage the client to perform? 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day.

4 The mother should be advised to wear a supportive bra 24 hours a day for a week or so.

Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neona- talogist to evaluate? 1. The neonate with a temperature of 97.9oF and weight of 3000 grams. 2. The neonate with white spots on the bridge of the nose. 3. The neonate with raised white specks on the gums. 4. The neonate with respirations of 72 and heart rate of 166.

4 The normal resting respiratory rate of a neonate is 30 to 60 and the normal resting heart rate of a neonate is 110 to 160.

A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her infant. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottlefeed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

4 The nurse should discuss the action of oxytocin.

A pregnant woman must have a glucose challenge test (GCT). Which of the fol- lowing should be included in the preprocedure teaching? 1. Fast for 12 hours before the test. 2. Bring a urine specimen to the laboratory on the day of the test. 3. Be prepared to have 4 blood specimens taken on the day of the test. 4. The test should take one hour to complete.

4 The test does take about 1 hour to complete.

A client is 35 weeks' gestation. Which of the following findings would the nurse ex- pect to see? 1. Nausea and vomiting. 2. Maternal ambivalence. 3. Fundal height 10 cm above the umbilicus. 4. Use of three pillows for sleep comfort.

4 The use of three pillows for sleep comfort is often seen in clients who are 35 weeks' gestation.

A woman whose prenatal weight was 105 lb weighs 109 lb at her 12-week visit. Which of the following comments by the nurse is appropriate at this time? 1. "We expect you to gain 1 lb per week, so your weight is a little low at this time." 2. "Most women gain no weight during the first trimester, so I would suggest you eat fewer desserts for the next few weeks." 3. "You entered the pregnancy well underweight, so we should check your diet to make sure you are getting the nutrients you need." 4. "Your weight gain is exactly what we would expect it to be at this time."

4 The weight gain is within normal for the first trimester.

A nurse is assessing a 1-day postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes.

4 This blood loss is excessive, especially for a postoperative cesarean section client. The surgeon should be notified.

The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6 ̊F, 82, 18; fundus firm at umbilicus; moderate lochia; ambulated to bathroom to void 4 times; breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? 1. Fluid volume deficit r/t excess blood loss. 2. Impaired skin integrity r/t vaginal delivery. 3. Impaired urinary elimination r/t excess output. 4. Knowledge deficit r/t lack of parenting experience.

4 This client is a primigravida. The nurse would anticipate that she is in need of teaching regarding infant care as well as self-care.

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to hospital to be evaluated. Which of the following statements by the woman in- dicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4 This client is exhibiting clear signs of true labor. Not only are the contrac- tions lasting a full minute but she isstating that they are so uncomfortable that she is unable to speak through them. She should be seen.

Which of the following actions is appropriate for the nurse to perform when caring for a Chinese-speaking woman in active labor? 1. Apply heat to the woman's back. 2. Inquire regarding the woman's pain level. 3. Make sure that the woman's head is covered. 4. Accept the woman's loud verbalizations.

4 This fetal pH value is within normal limits.

The partner of a gravida accompanies her to her prenatal appointment. The nurse notes that the father of the baby has gained weight since she last saw him. Which of the following comments is most appropriate for the nurse to make to the father? 1. "I see that you are gaining weight right along with your partner." 2. "You and your partner will be able to go on a diet together after the baby is born." 3. "I can see that you are a bad influence on your partner's eating habits." 4. "I am so glad to see that you are taking so much interest in your partner's pregnancy."

4 This is an appropriate comment to make at this time.

A 12-week gestation client tells the nurse that she and her husband eat sushi at least once per week. She states, "I know that fish is good for me, so I make sure we eat it regularly." Which of the following responses by the nurse is appropriate? 1. "You are correct. Fish is very healthy for you." 2. "You can eat fish, but sushi is too salty to eat during pregnancy." 3. "Sushi is raw. Raw fish is especially high in mercury." 4. "It is recommended that fish be cooked to destroy harmful bacteria."

4 This is correct. It is recommended that during pregnancy the client eat only well-cooked fish.

A client, G1P1001, 1-hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

4 This is the appropriate action by the nurse.

A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse's best response? 1. "I know that it hurts but it is very important for you to cough." 2. "Let me check your lung fields to see if coughing is really necessary." 3. "If you take a few deep breaths in, that should be as good as coughing." 4. "If you support your incision with a pillow, coughing should hurt less."

4 This is the appropriate response. The nurse is providing the client with a means of reducing the discomfort of postsurgical coughing.

It is 4 p.m. A client, G1P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies 1. "Laboring clients are never allowed to eat." 2. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." 3. "The dinner tray should arrive in an hour or two." 4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

4 This is the best response.

The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, "Oh, I don't use those. I always use tampons." Which of the following actions by the nurse is appropriate at this time? 1. Remove the peripad and insert a tampon into the woman's vagina. 2. Advise the client that for the first two days she will be bleeding too heavily for a tampon. 3. Remind the client that a tampon would hurt until the soreness from the delivery resolves. 4. State that it is unsafe to place anything into the vagina until involution is complete.

4 This response is correct. It is unsafe to place anything in the vagina before involution is complete.

A client, G1P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."

4 This response shows that the nurse has an understanding of the client's feelings.

A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? 1. "You must wait to begin to perform exercises until after your six-week postpar- tum checkup." 2. "You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe." 3. "By next week you will be able to return to the exercise schedule you had during your prepregnancy." 4. "You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks."

4 This statement is correct. The client should begin with Kegel exercises shortly after delivery, move to ab- dominal tightening exercises in the next couple of days, and then slowly progress to stomach crunches, and so on.

A client is having an ultrasound assessment done at her prenatal appointment at 8 weeks' gestation. She asks the nurse, "Can you tell what sex my baby is yet?" Which of the following responses would be appropriate for the nurse to make at this time? 1. "The technician did tell me the sex, but I will have to let the doctor tell you what it is." 2. "The organs are completely formed and present, but the baby is too small for any to be seen." 3. "The technician says that the baby has a penis. It looks like you are having a boy." 4. "I am sorry. It will not be possible to see which sex the baby is for another month or so."

4 This statement is true. The sex is not visible yet.

A woman, G2 P0101, 5 cm dilated and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following in- terventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Assist the woman in changing position. 4. Urge the woman to perform the next level breathing.

4 This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time.

Using the Neonatal Infant Pain Scale (NIPs), a nurse is assessing the pain response of a newborn who has just had a circumcision. A change in which of the following signs/symptoms is the nurse evaluating? Select all that apply. 1. Heart rate. 2. Blood pressure. 3. Temperature. 4. Facial expression. 5. Breathing pattern.

4 and 5 are correct. 1. Although assessed in other pain scales, the heart rate is not part of the NIPS scale. 2. Blood pressure is not assessed in any in- fant pain scale. 3. Temperature is not assessed in any infant pain scale. 4. Facial expression is one variable that is evaluated as part of the NIPS scale. 5. Breathing pattern is one variable that is evaluated as part of the NIPS scale. TEST-TAKING TIP: The student should be familiar with the pain-rating scales and use them clinically since neonates cannot communicate their pain to the nurse. The scoring variables that are evaluated when assessing neonatal pain using the NIPS scale are facial expression, crying, breathing patterns, movement of arms and legs, and state of arousal. Other pain assessment tools are the Pain Assessment Tool (PAT), the Neonatal Post-op Pain Scale (CRIES), and the Premature Infant Pain Profile (PIPP).

A 38-week gestation client, Bishop score 1, is advised by her nurse midwife to take evening primrose daily. The office nurse advises the client to report which of the following side effects that has been attributed to the oil? 1. Skin rash. 2. Pedal edema. 3. Blurred vision. 4. Tinnitus.

1 Evening primrose has been shown to cause skin rash in some women.

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2 Station is assessed by palpating the ischial spines.

While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the fol- lowing is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.

3 With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical.

A neonate is being admitted to the well-baby nursery. Which of the following find- ings should be reported to the neonatalogist? 1. Umbilical cord with three vessels. 2. Diamond-shaped anterior fontanelle. 3. Cryptorchidism. 4. Café au lait spot.

3 Undescended testes—cryptorcidism— is an unexpected finding. It is one sign of prematurity.

A woman, who is in active labor, is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? 1. The baby is in the breech position. 2. The baby is in the horizontal lie. 3. The baby's presenting part is engaged. 4. The baby's chin is resting on its chest.

4 When the baby's chin is on his or her chest, the baby is in the flexed attitude.

Below are four important landmarks of fetal development. Please place them in chronological order: 1. Four-chambered heart is formed. 2. Vernix caseosa is present. 3. Blastocyst development is complete. 4. Testes have descended into the scrotal sac.

The correct order is 3, 1, 2, 4. 3. The blastocyst is developed about 6 days after fertilization and before implantation in the uterus has occurred. 1. The four-chambered heart is formed during the early part of the first trimester. 2. Vernix caseosa is present during the lat- ter half of pregnancy. 4. The testes descend in the scrotal sac about mid third trimester. TEST-TAKING TIP: Before putting these items into chronological order, the test taker should carefully analyze each choice. The blastocyst is developed by about day 6 after fertilization. The egg has yet even to implant into the uterine body at this point. The fetal heart devel- ops during the early part of the first trimester, but after implantation. Vernix is present during the entire latter half of the pregnancy in order to protect the skin of the fetus. It appears, therefore, at about week 20. And, finally, the testes do not descend into the scrotal sac until mid third trimester. Indeed, male preterm ba- bies are often birthed before the testes descend.

A newborn was born weighing 3278 grams. On day 2 of life, the baby weighed 3042 grams. What percent of weight loss did the baby experience? _______ %

To determine how many grams the baby has lost, the test taker must subtract the new weight from the birth weight: 3278 -3042 =236 grams of weight loss Then, to determine the percentage of weight loss, the test taker must divide the difference by the original weight and multiply by 100%: 236/3278 = 0.0719 0.0719 x 100 = 7.19% TEST-TAKING TIP: To calculate percentage of weight loss, needed in a variety of clinical settings as well as in the neonatal nursery, the test taker must subtract the new weight from the old weight, divide the difference by the old weight, and then multiply the result by 100%.

A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.

1 When newborns are wet they can be- come hypothermic from heat loss re- sulting from evaporation. They may then develop cold stress syndrome.

The health care practitioner orders the following medication for a laboring client: Stadol 0.5 mg IV stat for pain. The drug is on hand in the following concentration: Stadol 2 mg/mL. How many mL of medication will the nurse administer? _____ mL

0.25 mL

The pediatrician has ordered vitamin K 0.5 mg IM for a newly born baby. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? ______ mL

0.25 mL

A postoperative cesarean section woman is to receive morphine 4 mg q 3-4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? ___________ mL

0.6 mL

A nurse who is caring for a mother/newborn dyad on the maternity unit has identi- fied the following nursing diagnosis: Effective breastfeeding. Which of the follow- ing would warrant this diagnosis? 1. Baby's lips are flanged when latched. 2. Baby feeds every 4 hours. 3. Baby lost 12% of weight since birth. 4. Baby's tongue stays behind the gum line.

1 Both the upper and lower lips should be flanged.

When analyzing the need for health teaching of a prenatal multigravida, the nurse should ask which of the following questions? 1. "What are the ages of your children?" 2. "What is your marital status?" 3. "Do you ever drink alcohol?" 4. "Do you have any allergies?"

3 This question is important to ask in order to determine a prenatal client's health teaching needs.

A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? 1. Encourage the parents to bond with their baby. 2. Notify the neonatalogist of the finding. 3. Perform the gestational age assessment. 4. Place the baby under the overhead warmer.

1 Babies are awake and alert for approx- imately 30 minutes to 1 hour immedi- ately after birth. This is the perfect time for the parents to begin to bond with their babies.

A woman states that she frequently awakens with "painful leg cramps" during the night. Which of the following assessments should the nurse make? 1. Dietary evaluation. 2. Goodell's sign. 3. Hegar's sign. 4. Posture evaluation.

1 A dietary evaluation is indicated since painful leg cramps can be caused by consuming too little calcium or too much phosphorus.

The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan? 1. Wash hands well before picking up the baby. 2. Refrain from having visitors for the first month. 3. Wear a mask to prevent transmission of a cold. 4. Sterilize the breast pump supplies for the first month.

1 Although this baby is being breastfed, he or she is still susceptible to illness. The best way to prevent transmission of pathogens is to wash hands care- fully before touching the baby.

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the doula to perform? 1. Give the mother a back rub. 2. Assess the fetal heart rate. 3. Check the blood pressure. 4. Regulate the intravenous.

1 An appropriate action by the doula is giving the woman a back massage.

Which finding would the nurse view as normal when evaluating the laboratory reports of a 34-week gestation client? 1. Anemia. 2. Thrombocytopenia. 3. Polycythemia. 4. Hyperbilirubinemia.

1 Anemia is an expected finding.

A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make? 1. Place a pillow in her lap. 2. Position the head of the baby in her elbow. 3. Put the baby on his back. 4. Move the breast toward the mouth of the baby.

1 This is true. The baby must be at the level of the breast in order to feed ef- fectively.

The nurse is conducting a state-mandated evaluation of a neonate's hearing. Infants are assessed for deficits because hearing-impaired babies are high risk for which of the following? 1. Delayed speech development. 2. Otitis externa. 3. Poor parental bonding. 4. Choanal atresia.

1 Babies learn to speak by imitating the speech of others in their environ- ment. If they are hearing impaired, there is a likelihood of delayed speech development.

To reduce the risk of hypoglycemia in a full-term newborn weighing 2900 grams, what should the nurse do? 1. Maintain the infant's temperature above 97.7oF. 2. Feed the infant glucose water every 3 hours until breastfeeding well. 3. Assess blood glucose levels every 3 hours for the first twelve hours. 4. Encourage the mother to breastfeed every 4 hours.

1 Hypothermia in the neonate is de- fined as a temperature below 97.7oF. Cold stress syndrome may develop if the baby's temperature is below that level.

A pregnant client is lactose intolerant. Which of the following alternative calcium- rich foods could this woman consume? 1. Turnip greens. 2. Green beans. 3. Cantaloupe. 4. Nectarines.

1 Turnip greens are calcium-rich.

An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply. 1. Amenorrhea. 2. Breast tenderness. 3. Quickening. 4. Frequent urination. 5. Uterine growth.

1, 2, 3, and 4 are correct. 1. Amenorrhea is a presumptive sign of pregnancy. 2. Breast tenderness is a presumptive sign of pregnancy. 3. Quickening is a presumptive sign of pregnancy. 4. Frequent urination is a presumptive sign of pregnancy. 5. Uterine growth is a probable sign of pregnancy. TEST-TAKING TIP: There are three classifi- cations of signs of pregnancy: presump- tive, probable, and positive. Signs that are totally subjective, or presumptive, in- clude amenorrhea, breast tenderness, quickening, and frequent urination. Signs that are objective, but not totally ab- solute, are termed probable and include alterations in uterine shape and size and softening of the cervix. Signs that are absolute, or positive, include hearing the fetal heartbeat, detecting fetal move- ment, and ultrasound images of the fetal outline.

Awomanhasjustcompletedherfirsttrimester.Whichofthefollowingfetalstruc- tures can the nurse tell the woman are well formed at this time? Select all that apply. 1. Genitals. 2. Heart. 3. Fingers. 4. Alveoli. 5. Kidneys.

1, 2, 3, and 5 are correct. 1. The genitalia are formed by the end of the first trimester. 2. The heart is formed by the end of the first trimester. 3. The fingers are formed by the end of the first trimester. 4. The alveoli will not be formed until well into the second trimester. 5. The kidneys are formed by the end of the first trimester. TEST-TAKING TIP: The test taker should be familiar with the basic developmental changes that occur during the three trimesters. In addition, the test taker should be able to develop a basic time- line of developmental milestones that occur during the pregnancy. By the conclusion of the first trimester, all major organs are completely formed. The maturation of the organ systems must, however, still occur.

A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal? Select all that apply. 1. Purple-colored patches on the buttocks and torso. 2. Bilateral whitish discharge from the breasts. 3. Bloody discharge from the vagina. 4. Sharply demarcated dark red area on the face. 5. Deep hair-covered dimple at the base of the spine.

1, 2, and 3 are correct. 1. The patches are called mongolian spots and they are commonly seen in babies of color. They will fade and disappear with time. 2. The whitish discharge is called witch's milk and is excreted as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. 3. The bloody discharge is called pseudomenses and occurs as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. 4. The demarcated area is a port wine stain, or capillary angioma. It is a permanent birthmark. 5. The dimple may be a pilonidal cyst or a small defect into the spinal cord (spina bifida). An ultrasound should be done to determine whether or not a pathological condition is present. TEST-TAKING TIP: A multiple response type of question is often a more difficult type of question to answer than is a stan- dard multiple choice item because there is not simply one correct response to the question. The test taker must look at each answer option to see whether or not it accurately answers the stem of the question. In this question, purple- colored patches, a whitish discharge from the breasts, and a bloody discharge in a female African American neonate are all considered normal and are temporary.

A woman has just arrived at the labor and delivery suite. In order to report the client's status to her primary health care practitioner, which of the following assess- ments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Contraction stress test. 4. Vital signs. 5. Biophysical profile.

1, 2, and 4 are correct. 1. The nurse should assess the fetal heart before reporting the client's status to the health care provider. 2. The nurse should assess the contrac- tion pattern before reporting the client's status. 3. A contraction stress test is only performed if ordered by a health care practitioner. 4. The nurse should assess the woman's vital signs before reporting her status. 5. A biophysical profile is only performed if ordered by a health care practitioner. TEST-TAKING TIP: The fetal heart, con- traction pattern, and maternal vitals all should be assessed in order to provide the health care practitioner with a pic- ture of the health status of the mother and fetus. In some institutions, the nurse may also do a vaginal examination to as- sess for cervical change.

A woman asks the nurse about the function of amniotic fluid. Which of the follow- ing statements by the woman indicates that additional teaching is needed? 1. The fluid provides fetal nutrition. 2. The fluid cushions the fetus from injury. 3. The fluid enables the fetus to grow. 4. The fluid provides a stable thermal environment.

1. The umbilical cord, not the amniotic fluid, delivers nutrition to the devel- oping fetus.

A woman who is seen in the prenatal clinic is found to be 8 weeks pregnant. She confides to the nurse that she is afraid her baby may be "permanently damaged be- cause I had at least 5 beers the night I had sex." Which of the following responses by the nurse would be appropriate? 1. "I would let the doctor know that if I were you." 2. "It is unlikely that the baby was affected." 3. "Abortions during the first trimester are very safe." 4. "An ultrasound will tell you if the baby was affected."

2 This statement is true.

A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the follow- ing needles could the nurse safely choose for the injection? 1. 5⁄8 inch, 18 gauge. 2. 5⁄8 inch, 25 gauge. 3. 1 inch, 18 gauge. 4. 1 inch, 25 gauge.

2 A 5⁄8-inch, 25-gauge needle is an ap- propriate needle for a neonatal IM in- jection.

A mother and her 2-day-old baby are preparing for discharge. Which of the follow- ing situations would require the baby's discharge to be cancelled? 1. The parents only own a car seat that faces the rear of the car. 2. The baby's bilirubin is 19 mg/dL. 3. The baby's blood glucose is 59 mg/dL. 4. There is a large bluish spot on the left buttock of the baby.

2 A bilirubin of 19 mg/dL is above the expected level. Therapeutic interven- tion is needed.

A nurse is discussing the serving sizes in the grain food group with a new prenatal client. Which of the following foods equals 1 serving size from the grain group? Select all that apply. 1. 1 bagel. 2. 1 slice of bread. 3. 1 cup cooked pasta. 4. 1 tortilla. 5. 1 cup dry cereal.

2, 4, and 5 are correct. 1. 1 bagel 2 servings. 2. 1 slice bread 1 serving. 3. 1 cup cooked pasta 2 servings. 4. 1 tortilla 1 serving. 5. 1 cup dry cereal 1 serving. TEST-TAKING TIP: The test taker should note that pregnant women are recom- mended to consume 7 to 11 servings of grain. However, 1 sandwich equals 2 servings since each piece of bread equals 1 serving. Also, it is important to counsel women to eat whole grain foods rather than processed grains. More nutrients as well as more fiber are obtained from whole grain foods.

The physician writes the following order for a newly admitted client in labor: Begin a 1000 cc IV of D5 1/2 NS at 150 cc/hr. The IV tubing states that the drop factor is 10 gtt/cc. Calculate the drip rate. _______ gtt/min

25 gtt/min

A nurse is assessing the bonding of the father with his newborn baby. Which of the following actions by the father would be of concern to the nurse? 1. He holds the baby in the en face position. 2. He calls the baby by a full name rather than a nickname. 3. He tells the mother to pick up the crying baby. 4. He falls asleep in the chair with the baby on his chest.

3 A father who expects his partner to quiet a crying baby may not be ac- cepting the parenting role.

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3 It is essential to assess the fetal heart rate immediately after an amniotomy.

A full-term baby's bilirubin level is 15 on day 3. Which of the following neonatal behaviors would the nurse expect to see? 1. Excessive crying. 2. Increased appetite. 3. Lethargy. 4. Hyperreflexia.

3 Lethargy is one of the most common early symptoms of hyper- bilirubinemia.

The nurse is examining a 2-day postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

3 This response is correct. The involu- tion is normal and the lochia is rubra.

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

4 A fetus in a scapular presentation is in a horizontal lie.

The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother.

4 Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby.

A multigravid client is 22 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit? 1. Nausea. 2. Dyspnea. 3. Urinary frequency. 4. Leg cramping.

4 Leg cramping is often a complaint of clients in the second trimester.

A client who was seen in the prenatal clinic at 20 weeks' gestation weighed 128 lb at that time. Approximately how many pounds would the nurse expect the client to weigh at her next visit at 24 weeks' gestation? 1. 129 lb. 2. 130 lb. 3. 131 lb. 4. 132 lb.

4 The woman would be expected to weigh about 132 lb. At this stage of pregnancy, the woman is expected to gain about 1 lb a week.

After a client's placenta is birthed, the obstetrician states, "Please add 20 units of oxytocin to the intravenous and increase the drip rate to 250 cc/hr." The client has 750 cc in her IV and the IV tubing delivers fluid at the rate of 10 gtt/cc. To what drip rate should the nurse set the intravenous? ______ gtt/min

42 gtt/min

The nurse is assessing a client who states, "I think I'm in labor." Which of the fol- lowing findings would positively confirm the client's belief? 1. She is contracting q 5 min 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2 Once the cervix begins to dilate, a client is in true labor.

Which of the following full-term babies requires immediate intervention? 1. Baby with seesaw breathing. 2. Baby with irregular breathing with 10-second apnea spells. 3. Baby with coordinated thoracic and abdominal breathing. 4. Baby with respiratory rate of 52.

1 Seesaw breathing is an indication of respiratory distress.

A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the following must the nurse include in her discharge teach- ing regarding the vaccine? 1. The woman should not become pregnant for at least 4 weeks. 2. The woman should pump and dump her breast milk for 1 week. 3. The mother must wear a surgical mask when she cares for the baby. 4. Passive antibodies transported across the placenta will protect the baby.

1 This statement is correct. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if the woman becomes pregnant within 4 weeks of receiving the injection.

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity.

1, 2, 3, and 5 are correct. 1. Before proceeding with a physical as- sessment, the nurse should check the client's weight gain reported in her prenatal record. 2. The client's ethnicity and religion should be noted before physical assess- ment. This allows the nurse to pro- ceed in a culturally sensitive manner. 3. The client's age should also be noted before the physical assessment is begun. 4. The type of insurance the woman has is not relevant to the nurse. 5. The client's gravidity and parity—how many times she has been pregnant and how many times she has given birth—should also be noted before a physical assessment is begun. TEST-TAKING TIP: The prenatal record is a summary of the woman's history from the time she entered prenatal care until the record was sent to the labor room (usually at about 36 weeks' gestation). Virtually all of the physical and psy- chosocial information relating to this woman is pertinent to the care by the nurse. For example, if a woman has gained very little weight during her preg- nancy, the baby may be small-for- gestational age. The nurse may also have to change his or her care in relation to the woman's ethnicity and religion, etc.

A nurse is performing a postpartum assessment on a newly delivered client. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

1, 3, 4, and 5 are correct. 1. The nurse should palpate the breasts to assess for fullness and/or engorgement. 2. The postpartum assessment does not in- clude carotid auscultation. 3. The nurse should check the client's vaginal discharge. 4. The nurse should assess the client's extremities. 5. The nurse should inspect the client's perineum. TEST-TAKING TIP: The best way to re- member the items in the postpartum as- sessment is to remember the acronym BUBBLEHE. The letters stand for: B—breasts; U—uterus; B—bladder; B—bowels and rectum (for hemor- rhoids); L—lochia; E—extremities; H—Homan's sign; and E—emotional status. Each of these items should be assessed during every postpartum assessment.

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2cm. 2. 4cm. 3. 8cm. 4. 10 cm.

2 This comment is consistent with a woman in the transition phase of stage 1.

A mother is attempting to latch her newborn baby to the breast. Which of the fol- lowing actions are important for the mother to perform in order to achieve effec- tive breastfeeding? Select all that apply. 1. Place the baby on his or her back in the mother's lap. 2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

2, 3, and 4 are correct. 1. The baby should be placed "tummy-to- tummy" with the mother. Babies cannot swallow when their heads are turned. They must face the breast for effective feeding. 2. To achieve an effective latch of both the nipple and the areolar tissue, the baby must have a wide-open mouth. 3. Because the neonate's mouth muscles are relatively weak, it is important for the baby to be placed at the level of the breast. If the baby is placed lower, he or she is likely to "slip to the tip" of the nipple and cause nipple abrasions. 4. Babies latch best when they are posi- tioned at the breast, in preparation to opening their mouths, with their noses pointed toward their mothers' nipples. 5. The baby's tongue must be below the nipple to achieve effective suckling. TEST-TAKING TIP: The test taker must re- member that positioning of a baby at the breast is much different from positioning a bottlefed baby. For example, even though bottlefed babies feed effectively while lying on their backs, breastfeeding will be unsuccessful in the same position.

Which of the following developmental features would the nurse expect to be absent in a 41-week gestation fetus? 1. Fingernails. 2. Eye lashes. 3. Lanugo. 4. Milia.

3 Because this baby is postterm, lanugo would likely not be present.

The nurse discusses sexual intimacy with a pregnant couple. Which of the follow- ing should be included in the teaching plan? 1. Vaginal intercourse should cease by the beginning of the third trimester. 2. Breast fondling should be discouraged because of the potential for preterm labor. 3. The couple may find it necessary to experiment with alternate positions. 4. Vaginal lubricant should be used sparingly throughout the pregnancy.

3 With increasing size of the uterine body, the couple may need counseling regarding alternate options for sexual intimacy.

When assessing the fruit intake of a pregnant client, the nurse notes that the client usually eats 1 piece of fruit per day and drinks 7 to 8 servings of fruit juice per day. Which of the following is the most important communication for the nurse to make? 1. "You are effectively meeting your daily fruit requirements." 2. "Fruit juices are excellent sources of folic acid." 3. "It would be even better if you were to consume more whole fruits and less fruit juice." 4. "Your fruit intake far exceeds the recommended daily fruit intake."

3 t is recommended that pregnant clients eat whole fruits rather than consume large quantities of fruit juice. This is the most important statement for the nurse to make.

To check for the presence of Epstein's pearls, the nurse should assess which part of the neonate's body? 1. Feet. 2. Hands. 3. Back. 4. Mouth.

4 Epstein's pearls—small white specks (keratin-containing cysts)—are lo- cated on the palate and gums.

The nurse asks a 31-week gestation client to lie on the examining table during a prenatal examination. In which of the following positions should the client be placed? 1. Orthopneic. 2. Lateral-recumbent. 3. Sims'. 4. Semi-Fowler's.

4 The client should be placed in a semi- Fowler's position.

A bottlefeeding woman, 11⁄2 weeks postpartum from a vaginal delivery, calls the ob- stetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1. "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." 2. "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." 3. "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." 4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

4 This response is appropriate. The client should be examined to assess her involution.

A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections.

1 This response is correct. Reassuring the client is appropriate.

The nurse is caring for a pregnant client who is a vegan. Which of the following foods should the nurse suggest the client consume as substitutes for restricted foods? 1. Tofu, legumes, broccoli. 2. Corn, yams, green beans. 3. Potatoes, parsnips, turnips. 4. Cheese, yogurt, fish.

1 Tofu, legumes, and broccoli are excel- lent substitutes for the restricted foods.

A nurse is advising a pregnant woman about the danger signs of pregnancy. The nurse should teach the mother that she should notify the physician immedi- ately if she experiences which of the following signs/symptoms? Select all that apply. 1. Convulsions. 2. Double vision. 3. Epigastric pain. 4. Persistent vomiting. 5. Polyuria.

1, 2, 3, and 4 are correct. 1. Convulsions are a danger sign of pregnancy. 2. Double vision is a danger sign of pregnancy. 3. Epigastric pain is a danger sign of pregnancy. 4. Persistent vomiting is a danger sign of pregnancy. 5. Polyuria is not highlighted as a danger sign of pregnancy. TEST-TAKING TIP: The danger signs of pregnancy are signs or symptoms that can occur in an otherwise healthy pregnancy that are likely due to serious pregnancy complications. For example, double vision, epigastric pain, and blurred vision are symptoms of the hypertensive illnesses of pregnancy, and persistent vomiting is a symptom of hyperemesis gravidarum.

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

1, 2, and 5 are correct. 1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate. 2. The nurse should infuse Ringer's lac- tate before the woman is given re- gional anesthesia. 3. It is not necessary to place the woman in the Trendelenburg position. 4. The blood pressure will need to be mon- itored every 5 minutes for 15 minutes af- ter administration of the anesthesia, but not before. 5. The nurse should ask the woman to empty her bladder. TEST-TAKING TIP: Before any medication, whether analgesia or anesthesia, is ad- ministered during labor, the fetal heart should be assessed to make sure that the baby is not already compromised. Before regional anesthesia administration, a liter of fluid should be infused to increase the woman's vascular fluid volume. This will help to maintain her blood pressure after the epidural insertion. And the woman's bladder should be emptied because she will not have the sensation of a full blad- der once the epidural is in place.

Which of the following nonpharmacological interventions recommended by nurse midwives may help a client at full term to go into labor? Select all that apply. 1. Engage in sexual intercourse. 2. Ingest evening primrose oil. 3. Perform yoga exercises. 4. Eat raw spinach. 5. Massage the breast and nipples.

1, 2, and 5 are correct. 1. Nurse midwives sometimes recom- mend that women at full term engage in sexual intercourse to stimulate labor. 2. Ingesting primrose oil is also some- times recommended. Primrose oil is believed to help ripen the cervix. 3. Exercise should be encouraged through- out pregnancy, but it is not used for induction. 4. Raw spinach is an excellent source of iron as well as a source of calcium and fiber. It is, however, not used for induction. 5. Nipple and breast massage is some- times recommended to help induce labor. TEST-TAKING TIP: If the test taker was unfamiliar with nonpharmacological in- duction methods, he or she could make some educated guesses by remembering that pharmacological medications for la- bor induction are prostaglandins and oxytocin. When a woman has an orgasm during intercourse, she releases oxytocin. Nipple and breast massage also stimulate oxytocin production. And evening prim- rose oil contains a fatty acid that con- verts into a prostaglandin compound.

A nurse is advising a couple of a newborn regarding when they should call their pe- diatrician. Which of the following responses show that the teaching was effective? Select all that apply. 1. If the baby repeatedly refuses to feed. 2. If the baby's breathing is irregular. 3. If the baby has no tears when he cries. 4. If the baby is repeatedly difficult to awaken. 5. If the baby's temperature is above 100.4oF.

1, 4, and 5 are correct. 1. Babies do not starve themselves. If a baby refuses to eat, it may mean that the baby is seriously ill. For example, babies with cardiac defects often refuse to eat. 2. Newborns normally breathe irregularly. Apnea spells of 10 seconds or less are normal. 3. Newborns do not tear when they cry. If a baby does tear, he or she may have a blocked lacrimal duct. 4. Although babies who are in the deep sleep state are difficult to arouse, the deep sleep state lasts no more than an hour. If the baby continues to be nonarousable, the pediatrician should be notified. 5. A temperature above 100.4oF is a febrile state for a newborn and the pediatrician should be notified. TEST-TAKING TIP: The test taker must judge each answer option independently of the others when completing a multiple response item. These items require more comprehensive knowledge since there is not simply one best response, but rather many correct answers.

Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply. 1. Act on the spur of the moment. 2. Create a diversion on the unit. 3. Ask questions about the routine of the unit. 4. Choose rooms near stairwells. 5. Wear over-sized clothing.

2, 3, 4, and 5 are correct. 1. Abductors usually plan their strategies carefully before taking the baby. 2. A common diversion is pulling the fire alarm to distract the staff. 3. Those who are inquisitive about where babies are at different times of the day may be planning an abduction. 4. Rooms near stairwells provide the abductor with a quick and easy get-away. 5. The abductor is able to hide a baby in oversized clothing or in large bags. TEST-TAKING TIP: The test taker should familiarize himself or herself with the many characteristics of the neonatal ab- ductor including, in addition to those cited above, individuals who are emo- tionally immature, suffer from low self- esteem, and have a history of manipula- tive behavior.

It is time for a baby, who is in the drowsy behavioral state, to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select all that apply. 1. Swaddle or tightly bundle the baby. 2. Hand express milk onto the baby's lips. 3. Talk with the baby while making eye contact. 4. Remove the baby's shirt and change the diaper. 5. Play pat-a-cake with the baby.

2, 3, 4, and 5 are correct. 1. Babies who are in the drowsy behavioral state and who are tightly swaddled often fall asleep rather than become aroused. 2. The smell and/or the taste of the milk often will arouse a drowsy baby. 3. Drowsy babies will open their eyes when placed in the en face position and are interacted with. 4. Performing manipulations like diaper- ing or playing pat-a-cake often will arouse a drowsy baby. 5. Performing manipulations like diaper- ing or playing pat-a-cake often will arouse a drowsy baby. TEST-TAKING TIP: It is important to dis- tinguish a drowsy baby from a baby in the quiet alert or active alert state. For example, a baby who is in the active alert state may actually benefit from being swaddled since he or she is upset and needs to be calmed. Conversely, a baby in a drowsy state may need to be stimu- lated by manipulating or playing with the baby or by expressing milk onto the baby's lips.

The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.

3 Cramping is an expected outcome of the administration of Methergine.

The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on third postpartum day. 2. Administer analgesics every four hours per doctor orders. 3. Teach client to contract her buttocks before sitting. 4. Irrigate incision twice daily with antibiotic solution.

3 This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the su- ture line.

A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding? 1. Holding the baby in the en face position. 2. Pushing down on the baby's lower jaw. 3. Tickling the baby's lips with the nipple. 4. Giving the baby a trial bottle of formula.

3 Tickling the baby's lips with the nip- ple is the recommended method of encouraging a baby to open his or her mouth for feeding.

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women? 1. Avoiding the discussion of uncomfortable procedures like vaginal exams and blood tests. 2. Focusing the discussion on baby care rather than labor and delivery. 3. Utilizing visual aids like movies and posters during the classes. 4. Having the classes at a location other than high school to reduce their embarrassment.

3 Using visual aids can help to foster learning in teens as well as adults.

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.

3 When a fetus is in the occiput poste- rior position, mothers frequently complain of severe back pain.

A client is complaining of severe back labor. Which of the following nursing inter- ventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Use a hydrotherapy tub.

3 When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head.

A neonate, who is being admitted into the well-baby nursery, is exhibiting each of the following assessment findings. Which of the findings must the nurse report to the primary health care provider? 1. Harlequin sign. 2. Extension of the toes when the lateral aspect of the sole is stroked. 3. Elbow moves past the midline when the scarf sign is assessed. 4. Telangiectatic nevi.

3 When the scarf sign is assessed, a premature baby would be able to move the elbow past the midline. A full-term baby would not be able to do this.

A 2-day-old neonate received a vitamin K injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective? 1. Skin color is pink. 2. Vital signs are normal. 3. Glucose levels are stable. 4. Blood clots after heel sticks.

4 This is the correct method of instilla- tion of the ophthalmic prophylaxis.

A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain? 1. The neonate's frenulum is attached to the tip of the tongue. 2. The baby's tongue forms a trough around the breast during the feedings. 3. The newborn's feeds last for 30 minutes every 2 hours. 4. The baby is latched to the nipple and to about 1 inch of the mother's areola.

1 Babies with short frenulums—tongue- tied babies—are unable to extend their tongues enough to achieve a suf- ficient grasp. Painful and damaged nipples often result.

During a preconception counseling session, the nurse encourages a couple to pre- pare a birth plan. Which of the following is the most important goal for this action? 1. Promote communication between the couple and health care professionals. 2. Enable the couple to learn about the types of medicine used in labor. 3. Provide the couple with a list of items that they should put in a bag for labor. 4. Give the high-risk couple a sense of control over having to have a cesarean.

1 Birth plans help to facilitate commu- nication between couples and their health care providers.

A nurse is discussing diet with a pregnant woman. Which of the following foods should the nurse advise the client to avoid consuming during her pregnancy? 1. Bologna. 2. Cantaloupe. 3. Asparagus. 4. Popcorn.

1 Bologna should not be consumed during pregnancy unless it is thor- oughly cooked.

The practitioner is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see? 1. Spontaneous fetal movement. 2. Fetal heart acceleration. 3. Increase in fetal heart variability. 4. Resolution of late decelerations.

2 A wedge should be placed under one side of the woman.

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? 1. Baby with respirations 42, oxygen saturation 96%. 2. Baby with Apgar 9/9, weight 4660 grams. 3. Baby with temperature 97.8oF, length 21 inches. 4. Baby with glucose 55 mg/dL, heart rate 121.

2 Although the Apgar score—9—is excellent, the baby's weight—4660 grams—is well above the average of 2500 to 4000 grams. Babies who are large-for-gestational age are at high risk for hypoglycemia.

A nurse concludes that a woman is in the latent phase of labor. Which of the fol- lowing signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate.

2 The woman is in early labor. There is no need for her to be hospitalized at this time.

Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottlefeed her child? 1. The woman with a neoplasm requiring chemotherapy. 2. The woman with cholecystitis requiring surgery. 3. The woman with a concussion. 4. The woman with thrombosis.

1 Breastfeeding is contraindicated when a woman is receiving chemotherapy.

The nurse has provided teaching to a post-op cesarean client who is being dis- charged on Colace (docusate sodium) 100 mg po tid. Which of the following would indicate that the teaching was successful? 1. The woman swallows the tablets whole. 2. The woman takes the pills between meals. 3. The woman calls the doctor if she develops a headache. 4. The woman does not worry when her urine turns orange.

1 Colace capsules should not be crushed, broken, or chewed.

Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit 39%. 2. White blood cell count 16,000 cells/mm3. 3. Red blood cell count 5 million cells/mm3. 4. Hemoglobin 15 grams/dL.

2 The nurse would expect to see an ele- vated white cell count.

A mother confides to a nurse that she has no crib at home for her baby. The mother asks the nurse which of the following places would be best for the baby to sleep. Of the following choices, which location should the nurse suggest? 1. In bed with his 5-year-old brother. 2. In a waterbed with his mother and father. 3. In a large empty dresser drawer. 4. In the living room on a pull-out sofa.

3 A large empty drawer has a firm bot- tom so that the baby is unlikely to rebreathe his or her own carbon dioxide and the sides of the drawer will prevent the baby from falling out of "bed."

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable informa- tion regarding the client's labor status? 1. Leopold's maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

4 A vaginal examination will provide the nurse with the best information about the status of labor.

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? 1. The woman has an internal laceration. 2. The woman is about to deliver the placenta. 3. The woman has an atonic uterus. 4. The woman is ready to expel the cord bloods.

The order of change during the third stage of labor is: 3, 4, 1, 2 3. The contraction of the uterus after deliv- ery of the baby is the first step in the third stage of labor. 4. As the uterus contracts, its surface area decreases more and more. 1. A hematoma forms behind the placenta as the placenta separates from the uterine wall after the uterus has contracted and its surface area has decreased. 2. The membranes separate from the uter- ine wall after the placenta separates and begins to be born. TEST-TAKING TIP: The test taker should become familiar with the process of pla- cental separation. Once the baby is born, the uterus contracts. When it does so, the surface area of the internal uterine wall decreases, forcing the placenta to begin to separate. As the placenta sepa- rates, a hematoma forms behind it, further promoting placental separation. Once the placenta separates and begins to be born, the membranes peel off the uterine wall and are delivered last.